UC-NRLF 


M71 


GIFT   OF 


DOCUMENTS 
DEFT. 


65TH  CONGRESS  \  o-c-w  A  TV  (  DOCUMENT 

SENATE  ]     No.  167 


TRAINING  OF  TEACHERS 

FOR  OCCUPATIONAL  THERAPY  FOR  THE 

REHABILITATION  OF  DISABLED  SOLDIERS 

AND  SAILORS 


LETTER 

FROM  THE 

US,  FEDERAL  BOARD  FOR  VOCATIONAL  EDUCATION 

TRANSMITTING, 

IN  RESPONSE  TO  A  SENATE  RESOLUTION  OF  JANUARY  27,  REPORT 

ON  A  STUDY  OF  THE  FEDERAL  BOARD  ENTITLED  "REHABILITATION 

OF  DISABLED  SOLDIERS  AND  SAILORS  AND  TEACHER  TRAINING 

FOR  OCCUPATIONAL  THERAPY" 


JANUARY  30, 1918— Referred  to  the  Committee  on 
Education  and  Labor  and  ordered  to  be  printed 


WASHINGTON 

GOVERNMENT  PRINTING  OFFICE 
1918 


FEDERAL  BOARD  FOR  VOCATIONAL  EDUCATION. 

MEMBERS. 

DAVID  F.  HOUSTON,  Chairman,  P.  P.  CLAXTON, 

Secretary  of  Agriculture.  Commissioner  of  Education. 

WILLIAM  C.  REDFIELD,  JAMES  P.  MUNROE, 

Secretary  of  Commerce.  Manufacture  and  Commerce. 

WILLIAM  B.  WILSON,  CHARLES  A.  GREATHOUSE,  Agriculture. 

Secretary  of  Labor.  ARTHUR  E.  HOLDER,  Labor. 

EXECUTIVE   STAFF. 

C.  A.  PBOSSER,  Director. 

LAYTON  S.  HAWKINS,  JOSEPHINE  T.  BERRY, 

Assistant  Director  for  Assistant  Director  for 

Agricultural  Education.  Home  Economics  Education. 

LEWIS  H.  CARRIS,  CHARLES  H.  WINSLOW, 

Assistant  Director  for  Assistant  Director  for  Research. 

Industrial  Education. 
CHEESMAN  A.  HERRICK, 

Special  Agent  for  Commercial  Education. 

2 


UB557 

' 


DEPT. 


S.  RES.  189. 


IX  THE  SEXATE  OF  THE  UNITED  STATES. 

JANUARY  28,  1918. 

Mr-  SMITH  of  Georgia  submitted  the  following  resolution ;  which  was  consid- 
ered and  agreed  to. 


RESOLUTION. 

1  Resolved,  That  the  Federal  Board  for  Vocational  Educa- 

2  tion  be  directed  to  furnish  to  the  Senate  such  information  as  it 

3  may  have  or  can  readily  obtain  on  the  rehabilitation  and  voca- 

4  tional  reeducation  of  crippled  soldiers  and  sailors. 

3 


371847 


LETTER  OF  TEANSMITTAL. 


FEDERAL  BOARD  FOR  VOCATIONAL  EDUCATION, 

Washington,  January  29, 1918. 

SIR  :  The  Federal  Board  for  Vocational  Education  is  in  receipt  of 
the  following  resolution  of  the  Senate  of  January  28,  1918 : 

Resolved,  That  tlie  Federal  Board  for  Vocational  Education  be  directed  to 
furnish  to  the  Senate  such  information  as  it  may  have  or  can  readily  obtain 
on  the  rehabilitation  and  vocational  reeducation  of  crippled  soldiers  and  sailors. 

Pursuant  thereto  there  is  herewith  transmitted  a  study  by  the 
Federal  board  entitled  "  The  rehabilitation  of  disabled  soldiers  and 
sailors,  and  teacher  training  for  occupational  therapy." 
Respectfully, 

JAMES  P.  MUNROE, 

Vice  Chairman. 
Hon.  THOMAS  E.  MARSHALL, 

President  United  States  Senate,  Washington,  D.  C. 


CONTENTS. 

Page. 

Foreword 9 

Introduction 11 

PART  I. 

The  problem  of  training  teachers 15 

Problems  in  teaching  the  war  invalids 15 

Readjustment  to  civil  life 18 

Classification  of  disabled  men  according  to  impairment  of  working  capacity .  20 

(a)  Men  not  able  to  compete  under  any  conditions 20 

(6)  Men  not  able  to  compete  after  completion  of  medical  treatment. . .  20 

(c)  Men  able  to  compete  after  completion  of  medical  treatment 20 

Chart  showing  stages  of  occupational  treatment  in  hospitals  and  teacher 

training 22 

Organization 23 

Selection  of  instructors  for  invalid  occupations 24 

Selection  of  instructors  for  occupational  therapy 24 

Course  of  study 25 

I  The  problem  of  rehabilitation 25 

II  Study  of  occupational  therapy  in  convalescent  cases  of  internal 

diseases,  injuries,  and  post-surgical  treatment  (not  orthopedic). .  25 

III  Study  of  occupational  therapy  in  relation  to  orthopedic  treatment.  25 

IV  Study  of  occupational  therapy  in  mental  and  nervous  disorders. .  26 

V  Technique  of  occupational  therapy 26 

VI  Study  of  occupations  in  relation  to  occupational  therapy 26 

VII  Methods  of  teaching 26 

VIII  The  curative  workshop 27 

Qualifications  of  teachers  for  directing  occupational  therapy . 27 

Qualifications  of  teachers  for  vocational  education " 31 

Equipment. 32 

(a)  Invalid  occupations 32 

(&)  Occupational  therapy 33 

PART  II. 

Functions  of  occupational  therapy 35 

Psychological  functions 35 

Physiological  functions 37 

Internal  diseases,  injuries  and  post-surgical  treatment  (not  orthopedic) .  39 

Orthopedic  surgery 41 

Occupational  therapy  and  the  war  invalid 42 

Mental  and  nervous  disorders 43 

Internal  diseases,  injuries,  and  post-surgical  treatment  (not  orthopedic) .  45 

Orthopedic  surgery 46 

The  need  for  immediate  occupation 48 

The  present  field  of  occupational  therapy,  and  its  possibilities  of  development.  48 

PART  III. 

Social  and  economic  aspects  of  occupational  therapy 52 

Advisability  of  practical  work 52 

Remuneration  of  men  in  workshops 55 

Marketable  products 56 

Overlapping  of  stages  of  rehabilitation 57 

Contributions  of  vocational  expert 58 

(a)  Occupational  direction 60 

(6)  Classification  of  duties  of  vocational  expert 61 

7 


8  CONTEXTS. 

Social  and  economic  aspects  of  occupational  therapy — Continued.  Page. 

Control  of  men  during  reeducation  .  .; 61 

Permanent  provision  for  disabled  men 65 

Demobilization .  P 66 

Value  of  civilian  strength  and  vitality 66 

(a)  Rehabilitation  of  the  "undesirable '' 66 

(6)  Rehabilitation  of  the  "unfit" 66 

(c)  Rehabilitation  of  the  industrially  handicapped 67 

Necessity  for  occupational  therapy  at  all  times 67 

Value  of  the  handicapped 69 

Letters  from  rehabilitated  soldiers 69 

Suggested  registration  and  record  blanks  for  charting  progress  of  patients. .  72 

Hospital  registration 

Curative  workshop  weekly  record 

Hospital  discharge 75 

Vocational  school  weekl  v  record r 76 


REHABILITATION  OF  DISABLED  SOLDIERS  AND  SAILORS— TEACHER 
TRAINING  FOR  OCCUPATIONAL  THERAPY. 


FOREWORD. 

Not  the  least  of  the  war  problems  in  the  field  of  vocational  educa- 
tion is  the  industrial  rehabilitation  of  the  disabled  soldier  and  sailor. 
Kealizing  that  if  the  United  States  was  to  avoid  the  serious  mistakes 
made  by  several  of  the  belligerent  nations  in  their  early  attempts  to 
solve  this  problem,  the  Federal  Board  for  Vocational  Education,  on 
August  16,  1917,  authorized  its  research  division  to  investigate  thor- 
oughly and  at  the  earliest  possible  moment  the  entire  question  of  the 
rehabilitation  of  war  cripples. 

A  preliminary  survey  of  the  experience  of  the  European  nations 
since  the  beginning  of  the  great  war  had  convinced  the  board  that  it 
was  necessary  to  develop  facts  from  every  source  for  the  formulation 
of  a  broad  and  comprehensive  plan  for  the  restoration  of  men, 
handicapped  as  a  direct  outcome  of  their  military  employment,  to 
useful  industrial  employment.  This  study  aims,  therefore,  to  build 
upon  such  information  as  was  available  before  the  war,  to  enrich 
and  complete  it  with  the  abundant  foreign  experience  gained  since  the 
war.  and  to  anticipate  the  problems  of  demobilization  which  will  far 
outlast  the  war  itself  and  which  will  conserve  in  handicapped  labor 
a  resource  of  great  economic  value. 

Rehabilitation,  whether  of  the  war  or  of  industrial  cripples,  de- 
pends to  a  large  extent  on  the  practice  of  occupational  therapy  dur- 
ing convalescence.  In  the  present  moment  of  preparation  the  United 
States  discovers  at  once  the  great  need  for  occupational  therapeutists 
and  an  equally  great  shortage  in  the  supply.  It  is  the  principal  pur- 
pose of  the  study  presented  in  this  document  to  attempt  to  meet  this 
situation,  to  show  what  methods  Europe,  after  costly  experiment,  has 
found  to  be  the  best,  to  outline  courses  for  the  emergency  training  of 
teachers,  and  to  map  out  the  essentials  of  a  complete  national  pro- 
gram of  rehabilitation. 

This  study  was  made  by  Elizabeth  G.  Upham,  under  the  direction 
of  Charles  H.  Winslow,  Assistant  Director  for  Research.  Acknowl- 
edgment for  valuable  suggestions  is  made  to  Dr.  William  Rush  Dun- 
ton,  jr.,  President  of  the  National  Society  for  the  Promotion  of  Oc- 
cupational Therapy  and  Instructor  of  Psychiatry,  Johns  Hopkins 
University,  Baltimore ;  to  Dr.  J.  Madison  Taylor,  Associate  Professor 
of  Nonpharmaceutic  Therapeutics  in  the  Medical  Department  of 
Temple  University,  Philadelphia;  to  Dr.  Frankwood  E.  Williams. 
Vice  Chairman  of  the  Mental  Hygiene  War  Work  Committee  of  the 
National  Committee  for  Mental  Hygiene;  to  Dr.  Shepherd  Ivory 
Franz,  Chairman  of  the  Committee  on  Rehabilitation  of  Maimed  and 
Crippled  of  the  Council  of  National  Defense ;  to  T.  B.  Kidner,  Voca- 
tional Secretary  of  the  Canadian  Military  Hospitals  Commission, 
and  to  officers  of  the  Surgeon  General's  Staff  of  the  War  Department. 

C.  A.  PROSSER,  Director. 


INTRODUCTION. 

Disabled  soldiers  and  sailors  are  now  returning  to  the  United 
States  from  the  theater  of  war,  and  the  situation  created  by  their 
return  is  one  that  calls  for  immediate  action  by  the  Federal  Gov- 
ernment. The  purely  emergency  problems  involved  in  the  ques- 
tion of  the  industrial  rehabilitation  of  these  men,  great  as  they  are, 
are  only  a  part  of  the  ever-present  problem  arising  from  the  fact  that 
a  much  larger  number  of  men  are  annually  crippled  and  handicapped  V 
in  the  ordinary  course  of  industry.  The  present  study  attempts  to  * 
analyze  broadly  the  fundamentals  of  these  problems,  emphasizing 
particularly,  however,  the  more  pressing  military  aspects.  It  is  to 
be  hoped  that  whatever  program  may  be  adopted  will  serve  not  for 
the  period  of  the  war  alone,  to  be  discarded  at  its  close,  but  also  for 
the  solution  of  the  rehabilitation  of  the  industrially  handicapped. 

Between  the  time  when  the  disabled  soldier  or  sailor  enters  the 
hospital  and  his  final  placement  in  industry,  commerce,  agriculture, 
or  less  frequently  in  the  special  workshop  or  home,  there  lies  a  long 
period  of  reeducation  and  adaptation.  In  this  period  such  terms  as 
"  invalid  or  bedside  occupations,"  "  occupational  therapy,"  "  curative 
workshop,"  and  "vocational  education"  are  commonly  used.  Each 
of  these  terms  refers  to  some  process  of  the  rehabilitation.  The  dis- 
tinct function  of  each,  however,  their  overlapping  and  interdepend- 
ence are  but  vaguely  understood,  and  therefore  require  definition.1 

The  different  disabilities,  physical  and  mental  complications,  the 
capabilities  and  experiences  of  the  disabled  soldier  or  sailor,  are  such 
that  the  problem  of  his  rehabilitation  is  in  each  case  an  individual 
problem,  and  complete  standardization  of  either  medical  or  occupa- 
tional treatment  is  impossible.  In  the  main,  however,  the  average 
program  for  a  man  incapacitated  for  further  military  service  over- 
seas may  be  described  as  follows : 

First,  a  period  of  acute  illness  or  surgical  care ;  second,  a  period  of 
convalescence,  frequently  of  long  duration ;  third,  vocational  reedu- 
cation. These  stages  may  merge  imperceptibly  into  one  another  or 
they  may  be  separate  and  distinct.  In  many  instances  one  or  two 
of  the  stages  may  be  altogether  omitted. 

JA  confusion  exists  between  invalid  or  bedside  occupations  and  occupational  therapy. 
Institutions  offering  instruction  to  teachers  in  occupational  therapy  are  giving  identical 
courses  with  those  offering  instruction  in  invalid  occupations.  Invalid  or  bedside  occupa- 
tions may  be  used  interchangeably,  as  they  cover  the  same  field  It  has  been  expedient  in 
this  study  to  draw  the  distinction  between  invalid  occupations  and  occupational  therapy, 
reserving  for  occupational  therapy  work  of  a  serious  and  educative  type.  The  thera- 
peutic value  of  invalid  or  bedside  occupations  is,  however,  fully  appreciated.  It  is  impos- 
sible to  give  a  complete  list  of  all  the  institutions  and  hospitals  in  this  country  offering 
courses  in  "  invalid  occupations."  Notable  among  them  are  : 

The  Experimental  Station  of  Invalid  Occupation,  conducted  by  Miss  Susan  E.  Tracy, 
Jamaica  Plains,  Mass. 

Dr.  Wm.  Rush  Dunton,  jr.,  course  for  nurses  at  the  Sheppard  and  Enoch  Pratt 
Hospitals,  Towson,  Md. 

Columbia  University,  department  of  nursing  and  health. 

The  Red  Cross  class  conducted  by  Mrs.  Eleanor  Clarke  Slagle  in  Chicago. 

The  Chicago  School  of  Civics  and  Philanthropy,  in  cooperation  with  the  Henry  B. 
Pavllle  School  of  Occupations,  is  offering  a  course  for  institutional  workers. 

The  Henry  B.  Faville  School  of  Occupations  of  the  Illinois  Society  for  Mental  Hygiene 
offers  a  course  in  training  teachers  for  invalid  occupations  and  occupational  therapy.  It 
gives  instruction  in  occupational  therapy  to  the  extent  that  many  of  the  materials  han- 
dled are  the  raw  materials  of  industry  and  the  patients  learn  machine  processes  and  the 
use  of  lathes. 


12  TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL  THERAPY. 

As  a  rule  the  acute  condition  will  occur  overseas  unless  complica- 
tions or  surgical  operation  take  place  after  the  patient  has  been  trans- 
ported to  the  United  States.  Patients  who  are  permanently  dis- 
abled for  further  military  service  will  be  brought  to  this  country  as 
soon  as  their  condition  permits,  thus  relieving  hospital  congestion  in 
France.  In  this  country,  furthermore,  not  only  are  supplies,  care, 
and  the  elaborate  equipment  needed  for  many  types  of  recovery 
accessible,  but  the  technical  schools  and  shops  for  vocational  training 
are  or  will  be  at  hand.  As  the  patient  recovers  from  the  first  acute 
convalescing,  he  may  be  given  "invalid  or  bedside  occupations." 
Occupational  therapy  and  the  curative  workshop  are  invaluable  in 
the  period  of  convalescence,  while  vocational  education  follows 
physical  recovery,  and  is  the  final  stage  in  rehabilitation.  The  three 
stages  are  necessarily  distinct  in  their  function,  and  call  for  distinct 
methods  of  teacher  training  and  different  kinds  of  equipment.  They 
respond  by  improved  conditions."  * 

During  the  close  of  the  first,  or  acute,  stage  of  illness  invalid  occu- 
pations is  sometimes  the  treatment.  This  is  desirable  in  cases  when 
the  patient's  disability  necessitates  his  staying  in  bed  for  a  consider- 
able length  of  time.  Not  only  w7ill  the  time  pass  more  quickly  for 
the  patient  so  employed  but  his  mental  outlook  wTill  be  improved, 
and  even  in  severely  restricted  positions  certain  activities  wrill  prove 
a  physical  benefit.  The  period  of  invalid  occupations  is  perhaps  the 
least  important  of  the  three  stages  in  rehabilitation,  since  it  usually 
covers  the  shortest  period  and  marks  the  interim  when  the  patient 
is  contending  against  the  greatest  number  of  limitations.  The  spe- 
cial object  of  invalid  occupations  is  to  help  the  wounded  man  feel 
that  he  is  not  wasting  time  and  to  save  him  from  self-pity  and  a 
brooding  condition  of  mind.  Even  those  who  accept  their  condition 
with  heroism  and  philosophy  become  depressed  as  a  result  of  the 
long  waiting  to  get  well.  Depression,  inertia,  and  worry  aggravate 
physical  conditions,  and  the  chief  duty  of  the  instructor  of  invalid 
occupations  is  to  shorten  the  period  of  unproductiveness  and  worry, 
and  if  he  can  "  prove  to  the  patient  who  chafes  against  his  limita- 
tions that  there  is  really  a  broad  highway  of  usefulness  opening  be- 
fore him  of  which  he  knew  not,  the  mental  friction  is  diminished  and 
satisfaction  steals  in,  while  the  whole  physical  organism  prepares  to 
respond  by  improved  conditions."  * 

While  the  occupations  given  in  this  early  stage  of  recovery  may 
have  a  therapeutic  effect,  they  can  not  always  be  of  practical  value  to 
the  patient's  economic  future  inasmuch  as  the  field  of  invalid  occupa- 
tions is  limited  to  the  bed  patient  or  to  the  patient  unable  to  attend 
classes  in  the  curative  workshop.  They  should  not  be  confused  with 
occupational  therapy,  which  is  more  comprehensive  and  belongs 
properly  in  the  second  or  convalescing  stage  of  rehabilitation.9 

1  Studies  in  Invalid  Occupations,  by  Susan  E.  Tracy. 

2  The   first  stage   was  not  considered   in   the   resolution   passed  at   the   interallied   con- 
ference held  in  Paris,  May  8-12,   1917.      The  following  two  stages   wore  considered   and 
differentiated  as  provided  by  resolution  No.  43  : 

"  The  reeducation  of  the  wounded  falls  into  two  period's  : 

"  3.  That  of  functional  restoration  by  work,  the  object  of  which  is  to  euro  the 
wounded,  prepare  them  for  instruction,  and  encourage  them  to  work. 

"  2.  That  of  technical  reeducation,  which  begins  as  soon  as  the  injuries  are  honied 
and  is  intended  to  restore  morally,  intellectually,  and  practically  those  who  have  limbs." 


TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL  THERAPY.  13 

Occupational  therapy  is  the  science  of  healing  by  occupation,  and 
the  curative  workshop  is  the  shop  where  the  convalescing  patients 
are  given  occupational  treatment.  Occupational  therapy  is  designed 
to  cover  the  long  and  tedious  periods  of  convalescence  when  the  pa- 
tient is  able  to  be  about,  when  medical  treatment  occupies  only  a  part 
of  his  day,  but  when  it  is  necessary  for  him  to  be  under  the  strictest 
medical  supervision.  Long  convalescence  is  characteristic  of  many 
of  the  disabilities  of  the  disabled  soldier  or  sailor,  such  as  general 
debility,  heart  trouble,  nerve  disorders,  tuberculosis,  rheumatism,  in- 
juries requiring  orthopedic  treatment,  etc. 

Vocational  training  takes  place  on  the  completion  of  convalescence 
or  when  the  patient  has  sufficiently  recovered  to  be  permitted  to. 
follow  a  prescribed  course  of  study.  Upon  vocational  training  de- 
pends the  employability  of  the  man  and  his  value  as  a  producing 
agent. 

Important  as  is  this  final  stage  in  rehabilitation,  its  success  de- 
pends upon  what  has  been  accomplished  by  occupational  therapy  in 
the  curative  workshop.  What  is  done  during  the  convalescent  stage 
forms  the  vital  link  between  medical  treatment  and  vocational  educa- 
tion or  economic  adjustment.  It  is  the  critical  and  most  important 
of  the  three  stages.  During  this  period,  ambition,  the  desire  for 
self-support  and  economic  usefulness  may  be  fostered,  replacing  the 
despair,  apathy,  and  dependence  often  experienced.  This  is,  more- 
over, the  period  when  the  patient  regains  the  functional  use  of  his 
body.  The  extent  to  which  he  becomes  reeducated  and  the  purpose 
and  end  to  which  that  reeducation  is  directed  make  not  only  pos- 
sible vocational  education  but  industrial  rehabilitation  as  well. 
While  many  of  the  patients  will  have  the  opportunity  to  complete 
the  training  begun  in  the  curative  workshop  in  the  vocational  school, 
many  others  will  be  able  to  go  directly  into  wage-earning  occupa- 
tions. The  period  of  occupational  therapy  must,  therefore,  be  used 
to  prepare  and  adjust  many  patients  to  civilian  life. 

Occupational  therapy  has  suddenly  received  world-wide  recogni- 
tion as  a  factor  indispensable  in  the  rehabilitation  of  wounded  sol- 
diers and  sailors.  The  participation  of  the  United  States  in  the  war 
and  the  establishment  of  an  elaborate  system  of  reconstruction  hos- 
pitals designed  to  rehabilitate  the  disabled,  necessitate  the  erection 
of  curative  workshops  and  the  training  of  teachers  of  occupational 
therapy.  It  is  timely,  therefore,  that  serious  attention  be  given  to 
the  study  of  occupational  therapy  in  order  to  determine  the  qualifi- 
cations of  its  teachers,  to  ascertain  its  function,  its  effect  upon  war 
invalids,  and  its  social  and  economic  aspects. 


PARTL 
THE  PROBLEM  OF  TRAINING  TEACHERS. 

The  problem  of  training  instructors  to  meet  the  war  need,  for 
teachers  capable  of  directing  occupational  treatment,  must  be  studied 
first  from  the  point  of  view  of  the  number  involved  and  the  prob- 
able number  of  teachers  required;  second,  special  problems  en- 
countered in  dealing  with  war  invalids ;  third,  qualifications  of  the 
instructors;  and  fourth,  course  of  training  for  teachers. 

Canadian  experience,  upon  which  the  figures  for  this  country  may 
be  based,  estimates  that  10  per  cent  of  the  men  sent  overseas  are  re- 
turned unfit  for  service.  Thirty  per  cent  of  these  are  in  the  hos- 
pitals at  one  time.  This  means  that  for  every  1,000,000  men  sent  over- 
seas, 100,000  will  come  back  permanently  disabled  for  further  mili- 
tary service  and  approximately  30,000  will  be  in  the  hospitals  at  one 
time.  The  majority  of  these  will  be  convalescent  patients.  Four 
instructors  are  estimated  in  Canada  to  every  100  convalescent 
patients.  Canada  is  endeavoring  to  increase  the  number  of  in- 
structors. 

In  Canada  the  men  go  to  the  shops  in  relays,  and  the  classes  run 
from  16  to  20  men,  often,  however,  considerably  less.  Allowing  4 
teachers  to  every  100  men,  1,200  occupational  therapeutists  would 
be  needed  for  every  million  men  overseas.  If  the  United  States 
maintains  an  over-seas  army  of  5,000,000,  6,000  instructors  will  be 
required.  For  the  best  results  there  should  be  a  higher  percentage 
than  4  instructors  for  every  100  men. 

The  war  invalid  presents  a  problem  that  is  distinct  from  that  of 
the  civilian  patient  or  the  industrially  handicapped.  The  indus- 
trially handicapped  person  is  more  frequently  alone  and  unaided. 
The  war  invalid,  on  the  contrary,  has  served  his  country,  and  the 
Nation  stands  ready  to  help  him.  At  his  service  are  a  multitude  of 
resources  and  agencies.  In  case  of  serious  injury,  the  pension  re- 
lieves him  from  apprehension  as  to  the  future.  Th^e  training  during 
convalescence  comes  at  a  time  when  mentally  and  physically  he  is 
most  responsive,  provided  he  is  stimulated;  and  the  military  au- 
thority which  it  is  possible  to  exercise  over  him,  but  not  over  a 
civilian  patient,  has  the  advantage  of  controlling  the  stubborn  and 
willful  patient  for  his  own  advantage. 

PROBLEMS  IN  TEACHING  THE  WAR  INVALIDS. 

The  records  reveal  that  a  few  of  the  patients  take  the  attitude 
that  they  have  done  their  part  and  that  others  may  look  out  for  them 
in  the  future.  The  majority  of  the  men,  however,  have  self-respect 

15 


16  TRAINING   OF    TEACHERS   FOR    OCCUPATIONAL   THERAPY. 

and  confidence;  they  have  made  good  in  the  face  of  danger,  and 
return  handicapped  but  determined  to  make  the  best  of  their  con- 
dition. The  care,  guidance,  and  patriotic  attitude  of  the  public, 
together  with  the  consciousness  on  the  part  of  the  patient  that  he  has 
served  his  country,  help  to  simplify  the  problem  of  the  returned 
soldier  or  sailor.  The  instructor  who  understands  how  to  approach 
the  sick,  who  has  sympathy  and  understanding  not  only  with  the 
subnormal  but  with  the  peculiar  mental  attitude  of  the  war  in- 
valid, and  who  knows  how  to  talk  his  own  language  to  him,  will 
find  the  disabled  man  a  responsible  and  willing  student. 

There  are,  however,  certain  difficulties  in  teaching  the  war  invalid 
which  do  not  exist  to  the  same ^  extent  in  the  case  of  the  civilian 
patient.  The  physical  handicap  is  likely  to  be  serious,  and  in  many 
oases  constitutes  a  permanent  disability.  The  instructor  must  there- 
fore take  his  past  into  consideration,  aiming  to  reduce  the  per- 
manent handicap  to  the  minimum  and  to  increase  to  the  maximum 
the  remaining  faculties  of  the  patient.  In  addition  to  the  physical 
disability,  the  mental  and  nervous  conditions  brought  on  by  the 
strain  of  trench  warfare  complicate  the  problem.  In  the  case  of  men 
whose  mental  and  nervous  condition  appears  quite  normal  there 
will  be  found  to  be  a  mental  sluggishness,  a  lack  of  concentration,  and 
a  nervous  fatigue  which  is  the  logical  outcome  of  the  experience  of 
modern  warfare.  Although  many  of  the  men  are  young  enough  to 
be  teachable,  the  instructor,  to  be  successful,  must  understand  the 
psychological  condition  of  the  disabled  soldier  or  sailor. 

Many  of  the  common  disabilities  involve  either  amputations  or 
inability  to  use  a  member.  Cheer  and  helpfulness  are  needed  in  the 
exercise  of  a  stump  or  in  teaching  a  man  to  be  skillful  with  his  left 
hand.1  In  many  cases  there  is  no  amputation,  but  the  limb  has 
ankylosed  or  remained  inactive  over  a  long  period,  and  here  again 
time,  patience,  and  encouragement  are  constantly  needed  in  order  to 
develop  the  first  feeble  muscular  exertions  into  forceful  and  produc- 
tive movements. 

The  fatigue  and  debility  suffered  by  many  of  the  patients  prevent 
long-continued  activity,  and  the  instructor  must  understand  the 
therapeutic  value  of  the  occupation  to  these  patients,  realizing  that 
this  value  can  not  be  measured  in. the  shop  by  the  tangible  results 
possible  to  obtain  in  some  cases.  ^ 

The  administering  of  occupational  treatment  in  the  cases  of  shell 
shock,  wrar  neuroses,  and  ps}rchoses  requires  the  most  expert  skill  and 
understanding  of  the  delicate  balance  and  relation  of  motor  functions 
to  the  central  nervous  system. 

The  totally  blind  and  deaf  are  fortunately  few.  Sudden  blindness 
or  deafness  coming  to  an  adult  renders  the  victim  far  more  helpless 
than  would  be  the  case  with  a  child  who  has  never  had  these  senses, 
or  with  an  adult  wrho  has  developed  a  certain  adjustment  through 
their  gradual  loss. 

1  The  method  devised  by  M.  Tamenne,  a  Belgian  refugee,  who  has  educated  his  left 
hand  most  proficiently  and  teaches  handwriting,  shorthand,  and  typewriting  to  those 
who  have  lost  the  use  of  their  right  hands  at  the  Ecole  Professionelle  de  Blesses  at 
Montpellier,  is  described  in  the  Lancet  for  Apr.  7,  1917.  M.  Tamenne  emphasizes  the 
psychological  value  of  having  the  pupil  write  as  nearly  like  his  former  hand  as  possible. 
Thus  he  has  an  unconscious  means  of  comparison,  and  when  he  has  imitated  his  normal 
handwriting  he  no  longer  feels  disabled.  M.  Tamenne  also  notes  the  necessity  of  giving 
the  patients  confidence,  and  of  teaching  them  to  consider  their  loss  not  a  disability,  but 
an  inconvenience  which,  may  be  overcome. 


TKAIX1XG   OF    TEACHERS  FOR  OCCUPATIONAL   THERAPY.  17 

The  blind1  must  be  "taught  to  be  blind,"  to  accept  their  lot  as  an 
inconvenience,  not  as  a  disability.  Intelligent  sympathy,  not  pity, 
will  assist  them  in  becoming  independent.  Blindness  imposes  a  se- 
vere nervous  strain  which  must  be  safeguarded.  The  method  of 
teaching  typewriting  and  Braille  to  the  blind  soldier  or  sailor  is 
the  same  as  teaching  any  victim  of  blindness.  It  must  not  be  sup- 
posed, however,  as  is  popularly  understood,  that  the  sudden  loss  of  a 
sense  develops  a  corresponding  sudden  acuteness  of  the  other  senses. 
The  sudden  loss  of  sight  is  in  itself  a  paralyzing  experience,  for  in 
addition  the  hearing  has  often  been  dulled  by  the  bursting  of  shells 
and  exposure,  and  the  manual  and  rough  work  of  army  life  has 
calloused  the  hands  so  that  many  patients  do  not  possess  a  sensitive 
1  ouch.  The  blind  soldier  or  sailor  requires  a  specially  trained  teacher 
for  the  blind,  and,  in  addition,  one  with  great  patience  and  apprecia- 
tion of  the  particular  handicap  of  the  war  invalid.2 

Under  the  head  of  deafness  should  be  included  both  the  dull  of 
hearing  and  the  totally  deaf.  A  resolution  passed  May  11,  1917,  at 
the  interallied  conference  held  in  Paris  states  that  "  lip  reading 
should  be  regarded  as  the  only  useful  method  of  reeducating  those 
who  are  totally  deaf."  Trained  teachers  of  the  deaf  are  the  only 
ones  who  should  be  intrusted  with  the  difficult  task  of  teaching  lip 
reading.  After  first  learning  the  lip  picture  of  a  few  written  words, 
the  patient  is  taught  to  read  forms  of  speech  of  the  first  and  second 
articulation  point  and  is  then  instructed  how  to  distinguish  different 
sounds  at  the  same  site  of  articulation.  Enthusiasm  must  be  main- 
tained, though  the  difficulties  of  lip  reading  for  the  adult  patients 
must  not  be  minimized.  As  the  patient  learns  to  read  lips,  simple, 
interesting  sentences  and  stories  must  be  recited,  preferably  those 
relating  to  experiences  with  which  he  is  familiar.3  The  patient 
should  be  taught  from  objects,  motions,  and  concrete  examples. 
This  treatment  applies  to  the  totally  deaf  whose  condition  is  organic. 
There  is  also  a  group  of  extremely  deaf  war  invalids  whose  difficulty 
is  mainly  functional.  Such  cases  respond  to  the  occupational  treat- 
ment of  war  neuroses.  For  such  patients  "  a  course  of  soothing 
and  fortifying  treatment  with  the  judicious  application  of  psycho- 
therapeutic  methods  and  organized  work  may  produce  unexpectedly 
brilliant  results." 4 

Although  the  concussions,  head  injuries,  and  vicissitudes  of  the  war 
do  not  cause  total  deafness  in  many  cases,  they  often  result  in  de- 
fective hearing.  The  returns  from  12  English  military  hospitals 

1  Resolution   87a,   passed  May   11,   1917,   at   the   interallied   conference,    provides   that 
"  The  creation  of  small  workshops  near  ophthalmic  centers  and  ophthalmic  departments 
in  hospitals  should  be  made  compulsory." 

2  The  great  success   of   Sir  Arthur  Pearson's   work   with   the   blind   at   St.    Dunstan's, 
England,  and  the  rapidity  with  which  the  men  learn,   has   been   attributed  to   the  fact 
that  he  favors  blind  teachers  as  instructors.     He  himself  is  blind.     The  men  are  encour- 
aged and  stimulated  to  learn  from  one  who  has  experienced  the  same  disability.     The 
following  is  an  extract  from  a  letter  written  by   Helen  Keller  to  the  American-British- 
French-Belgian  permanent  blind  relief  war  fund  : 

"  In  order  really  to  console  and  help  the  blind,  we  must  take  into  account  their  par- 
ticular needs,  their  peculiar  difficulties,  their  individual  capabilities.  *  *  *  Their 
lot  is  so  horrible  "  (the  maimed  as  well  as  blinded)  "  that  any  effort  to  break  through 
their  isolation  and  cheer  them  must  be  precious  beyond  our  powers  of  comprehension. 
*  *  *  If  we  have  the  will  and  courage  to  face  the  dark,  a  gentle  warmth  steals  into 
our  fearful  hearts.  *  *  *  We  are  so  constituted  that  we  can  adapt  ourselves  to 
almost  any  condition  if  only  a  friendly  hand  is  reached  out  to  us,  if  we  only  hold  fast 
to  our  faith  in  the  conquering  might  of  the  spirit." 

3  The  method  of  Director  Kroiss,  of  Wurzburg,  is  described  in  Recalled  to  Life,  June, 
1917 

*A  memorandum  prepared  by  Sir  Alfred  Keogh,  G.  C.  B.,  director  general,  army  med- 
ical service  for  the  AngJo-Belgian  committee. 

42298°— S.  Doc.  167.  65-2 2 


18  TRAINING    OF    TEACHERS   FOR   OCCUPATIONAL   THERAPY. 

show  that  1.4  per  cent  of  the  patients  suffered  from  some  form  of 
deafness.  Two  German  Army  corps  showed  a  percentage  of  disease 
or  injury  to  the  ear  as  high  as  7.5  in  a  year.  Many  of  these  cases  are 
capable  of  improvement,  and  total  deafness  may  be  prevented.  While 
lip  reading  is  desirable  for  many  of  these  cases,  it  is  important  that 
the  patients  use  and  exercise  what  hearing  they  have  and  take  ad- 
vantage of  all  mechanical  appliances  for  the  deaf.  It  is  a  character- 
istic of  the  deaf  to  be  depressed  and  expect  favors  on  account  of  their 
deafness.  Since  deafness  does  not  prohibit  men  from  entrance  into 
many  gainful  occupations,  it  is  necessary  that  the  instructor  be  not 
only  versed  in  the  technique  of  instructing  the  deaf,  but  that  he  also 
know  how  to  use  and  develpo  any  fragments  of  hearing  left  and 
overcome  any  natural  unfavorable  tendencies  of  temperament  occa- 
sioned by  the  deafness  likely  to  handicap  a  man  in  securing  employ- 
ment. 

READJUSTMENT  TO  CIVIL  LIFE. 

The  instructor  of  disabled  men  has  an  ambitious  purpose  to  accom- 
plish in  the  curative  workshop.  The  military  discipline  to  which  the 
men  have  long  been  accustomed  renders  difficult  the  adjustment  to 
civilian  life.  This  period  may  be  made  less  trying  if  the  instructor 
develops  individual  thinking  and  initiative  in  the  patients.  The 
recourse  to  military  discipline  in  the  curative  workshops  should  be 
rare.  Control  of  the  war  invalids  should  lie  in  the  instructor's  ability 
to  interest  them,  to  teach  them,  and  to  develop  in  them  regular  habits 
of  work,  habits  which  are  self-disciplinary  and  which  will  render 
the  men  valuable  members  of  civil  communities. 

French  experience  has  established  very  clearly  that  the  .selection  of  the 
right  type  of  teacher  is  vital  to  the  success  of  any  scheme  of  training.  The 
ordinary  technical  instructor  who  understands  his  subject  but  not  his  pupils  is 
quite  useless.  Teaching  the  physically  defective  is  not  perhaps  so  difficult  as 
teaching  the  mentally  defective,  but  it  requires  much  the  same  qualities,  the 
game  inexhaustible  patience,  the  same  blending  of  sympathy  and  firmness,  and, 
above  all,  the  power  of  appreciating  the  idiosyncrasies  of  the  different  pupils. 
The  ideal  instructor  must  know  his  men  as  well  as  his  trade.  He  must  study 
their  peculiarities  and  be  able  to  vary  his  methods  so  as  to  get  the  best  out  of 
each  man.1 

The  fact  that  the  majority  of  the  war  invalids  will  partly,  if  not 
wholly,  recover  makes  the  task  of  instruction  hopeful.  Inasmuch, 
however,  as  their  economic  independence  depends  to  a  large  extent 
upon  the  occupational  therapy  of  the  convalescent  period,  there  is 
imposed  upon  the  instructor  a  heavy  responsibility  not  only  to  help 
the  patient  to  get  hold  of  himself  and  thus  to  facilitate  his  recovery, 
but  to  furnish  him  with  that  accurate  knowledge  which  will  be  his 
vocational  equipment. 

Canadian  figures  show  that  80  per  cent  of  the  disabled  men  are 
able  to  return  to  their  former  industry  without  vocational  training, 
that  10  per  cent  need  complete  vocational  reeducation,  and  10  per- 
cent partial  reeducation.  It  therefore  follows  that  80  per  cent  of 
the  men  receive  no  further  instruction  after  leaving  the  curative 
workshop  and  that  20  per  cent  receive  varying  degrees  of  vocational 
reeducation.  The  last  opportunity  which  the  Federal  Government 

1  L.  G.  Brock,  in  American  Journal  of  Care  for  Cripples,  Vol.  IV,  No.  1. 


TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL   THERAPY.  10 

will  hare  to  assist  these  80,000 x  men  who  need  no  further  vocational 
education  in  the  task  of  adjusting  themselves  to  civilian  life  and  to 
the  demands  of  industry  will  be  during  the  period  of  convalescence 
in  the  curative  workshop.  The  problem  of  the  curative  workshop 
is,  then,  twofold — first,  to  provide  those  occupations  which  may 
facilitate  the  patient's  recovery  from  a  therapeutic  point  of  view; 
and,  second,  to  make  those  occupations  so  far  as  possible  of  such  a 
practical  type  that  the  patients  may  add  to  their  industrial  equip- 
ment. Intelligence  and  skill  is  the  workingman's  capital.  The  fact 
that  these  men  are  returned  unfit  for  further  military  service  indi- 
cates that  they  are  subnormal  in  some  slight  measure,  if  not  seriously 
and  permanently  handicapped. 

In  addition  to  those  men  who  will  become  employable  on  hospital 
discharge,  there  are  20  per  cent  who  can  only  become  so  after  par- 
tial or  complete  vocational  rehabilitation.  Since  many  of  these  men 
must  spend  a  long  convalescence  in  the  curative  workshop  before 
they  are  able  to  take  up  vocational  education,  it  will  save  time  and 
expense  to  make  the  course  of  instruction  in  the  hospital  workshop 
prevocational  to  the  course  which  the  patient  will  subsequently  fol- 
low. If  such  a  course  can  not  present  the  exact  processes,  either  be- 
cause of  lack  of  equipment  or  inability  on  the  patient's  part  to  per- 
form such  work  at  this  period  of  his  recovery,  it  may  at  least  con- 
tain allied  and  academic  subjects  which  will  form  a  valuable  back- 
ground to  technical  training. 

In  the  hospital  workshop  there  will  be  a  few  men  who  will  never 
be  able  to  compete  in  industry  and  for  whom  provision  will  have  to 
be  made  in  special  workshops. 

A  special  workshop  should  have  a  rest'  room  with  a  nurse  or  doc- 
tor in  constant  attendance.  It  should  have  as  many  comforts  as 
possible  in  the  way  of  special  devices,  foot  and  back  rests,  etc.  The 
hours  will  have  to  be  adjusted  to  each  patient.  Attendance  should 
be  as  regular  as  possible  and  discipline  should  be  consistent  with  the 
patient's  physical  condition.  There  should  be  classes  in  connection 
with  the  shop,  so  that  the  patients  may  increase  their  skill  and  so  that 
other  handicapped  persons  may  improve  their  time  while  out  of 
employment.  Every  effort  should  be  made  by  those  in  authority 
in  the  special  workshop  to  secure  employment  for  the  patients  out- 
side the  shop  whenever  it  is  possible  to  do  so.  The  patients  should 
receive  a  small  return  for  their  work,  and  the  character  of  the  work 
should  be  distinctly  commercial  and  should  compete  fairly  with  nor- 
mal prices.  In  all  probability  these  shops  can  not  be  self-supporting, 
since  labor  is  necessarily  dependent  upon  the  irregularity  and  uncer- 
tainty of  men  so  seriously  incapacitated  that  they  can  secure  employ- 
ment in  no  other  way.  The  deficit  incurred  by  such  an  establishment 
may  well  be  borne  by  the  Federal  Government  and  regarded  as  an 
economy  in  comparison  with  the  older  methods  of  caring  for  such 
cases  in  soldiers'  and  sailors'  homes,  where  the  men  are  maintained  in 
idleness  and  subject  to  mental  and  moral  deterioration.  The  cases 
for  the  special  workshops  are  fortunately  so  rare  after  the  modern 
method  of  hospital  treatment  that  they  are  negligible  in  number. 

1  On  the  basis  of  a  million  men  overseas,  Canadian  figures  give  10  per  cent,  or  100.000 
men,  returned  unfit  for  further  military  service  ;  SO  per  cent  of  them,  or  80,000,  are 
able  to  return  to  industry  without  vocational  education. 


20  TRAINING    OF    TEACHERS   FOR    OCCUPATIONAL   THERAPY. 

The  Lord  Roberts  Memorial  Workshops,  established  in  London, 
are  special  workshops  for  this  class  of  men.  In  the  first  year  a  profit 
of  £900  was  made  after  meeting  all  expenses  and  after  paying  £16.000 
in  wages  to  the  men  and  their  dependents. 

There  will  be  a  few  paralytics  and  bedridden  patients  who  will 
never  be  able  to  attend  even  special  workshops  for  the  handicapped. 
Bedside  and  invalid  occupations  may  pass  the  time  and  be  a  pallia- 
tive measure  for  this  last  group. 

CLASSIFICATION   OF  DISABLED   MEN    ACCORDING  TO   IMPAIRMENT   OF   WORK- 
ING   CAPACITY. 

The  following  classification  of  the  three  groups  of  patients  in  the 
curative  workshop  shows  the  degrees  of  disabilities  in  relation  to 
impairment  of  earning  capacity  and  clarifies  the  purpose  and  func- 
tion of  occupational  treatment  in  relation  to  each  group. 

(a)  Men  not  able  to  compete  in  normal  occupations  under  any  con- 
ditions.— Men  sufficiently  disabled  to  prevent  competition   in   any 
normal  occupation  so  that  they  will  be  employable  only  in  special 
workshops  upon  hospital  discharge.     For  this  group  invalid  occupa- 
tions and  even  occupational  therapy  can  be  both  a  palliative  measure 
and  an  economic  policy  within  limited  restrictions.     It  can  pass  the 
time,  keep  the  patient  contented,  and  later,  under  supervision  in 
special  workshops,  enable  him  to  be  partially  self-supporting. 

(b)  Men  not  able  to  compete  after  completion  of  medical  treat- 
ment.— Men  not  able  to  return  to  former  occupations  on  completion 
of  medical  treatment  but  able  to  become  self-supporting  in  new  voca- 
tions.    Occupational  therapy  is  of  the  greatest  value  to  this  class. 
Not  only  may  it  accelerate  their  recovery,  but  the  training  received 
in  convalescence  may  be  made  a  part  of  the  preparation  for  their  new 
vocations.     The  economy,  efficiency,  and  success  of  training  lie  in 
making  the  therapeutic  requirements  for  mind  and  body  in  con- 
valescence coincide  with   preparation   for  vocational   education,  if 
not  the  actual  vocational  training  itself.     (It  is,  of  course,  under- 
stood that  the  physical  condition  of  patients  in  the  curative  work- 
shop prevents  them  from  attending  regular  vocational  schools.) 

(c)  Men  able  to  compete  after  completion  of  medical  treatment. — 
Men  able  to,  return  to  former  vocations  on  the  completion  of  medical 
treatment.     Regulated   activity   and   wholesome   habit   of   work,   is 
designed  chiefly  to  facilitate  recovery.     Whenever  it  is  possible,  gen- 
eral education  classes  and  practice  in  the  workshop  should  increase 
the  patient's  economic  equipment  by  greater  knowledge  of  the  occu- 
pation with  which  he  is  already  familiar,  and  to  which  he  intends 
to  return  when  cured.      While  many  of  the  patients  will  be  learning 
to  perform  their  old  occupations  better,  many  others  must  go  through 
the  torturous  period  of  strict  reeducation,  not  in  the  sense  of  learning 
a  new  occupation,  but  in  learning  to  perform  an  already  familiar 
one  under  severe  limitations. 

It  is  now  clear  that  there  are  three  different  kinds  of  classes  in  the 
curative  workshops  at  the  same  time.  Moreover  the  length  of  time 
each  patient  may  work,  the  extent  to  which  he  may  exert  himself, 
and  the  kind  of  exercise  prescribed  must  be  determined  in  each  case 
by  the  individual.  Mr.  T.  B.  Kidner,  vocational  secretary  of  the 
Military  Hospitals  Commission  of  Canada,  has  pointed  out  the  desir- 


TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL  THERAPY.  21 

ability  of  having  the  classes  separated  not  only  according  to  subject, 
but  according  to  the  earnestness  with  which  the  men  may  work. 
Men  who  are  capable  of  applying  themselves  to  serious  vocational 
study,  although  still  in  the  curative  workshop,  should  not  be  mixed 
with  those  who  are  taking  training  merely  for  its  therapeutic  value 
or  with  those  who  are  incapable  of  making  even  a  fair  degree  of 
progress.  For  instance,  many  of  the  men  may  not  be  able  to  apply 
themselves  seriously  during  convalescence,  whereas  a  few  may  be  able 
to  work  fairly  hard  and  receive  great  benefit  from  a  vocational  course 
leading  directly  to  a  trade.  Such  patients  must  not  be  held  back  or 
they  will  develop  lazy  habits  of  wrork  and  cost  the  Government 
unnecessary  expense  by  lengthening  the  period  of  training. 

The  curative  workshop  must  be  a  departmental  institution  in  which 
there  are  many  occupations  affording  a  wealth  of  choice  both  from 
the  medical  and  economic  points  of  view.  This  is  necessitated  by  the 
different  interests,  possibilities  and  handicaps  of  the  men.  In  many 
cases  a  rudimentary  or  even  a  higher  education  is  advisable.  In 
other  cases  there  should  be  classes  in  commercial  education,  printing, 
drafting,  salesmanship,  agricultural  pursuits,  motor  mechanics,  and 
skilled  trades.  While  the  instruction  must  be  individual  and  the  con- 
dition and  fatigue  of  the  patient  must  form  the  basis  of  the  teaching 
in  each  case,  those  men  should  be  grouped  together  of  whom  the  same 
relative  degree  of  progress  can  be  expected. 

It  is  therefore  evident  that  the  director  must  be  familiar  with  the 
instruction  of  these  groups  and  with  a  wide  range  of  subjects.  He 
must  necessarily  possess  the  qualifications  of  the  manual-training 
teacher.  The  scheme  of  training  of  the  men  should  be  organized 
so  as  to  train  large  groups  of  people  at  one  place  rather  than 
small  and  scattered  groups  at  many  places.  This  will  make  pos- 
sible effective  use  of  the  coterie  of  teachers  who  are  specialists  in 
their  lines.  The  common  practice  of  schools  with  schemes  of  recita- 
tions and  assignment  of  work  can  be  followed  on  the  basis  of  what- 
the  different  teachers  are  able  to  contribute. 

The  chart  on  page  22  indicates  the  stages  of  occupational  treatment 
and  teacher  training  in  relation  to  each  group  of  men.  It  shows  the 
present  resources  for  training  each  group,  the  sources  from  which 
teachers  may  be  recruited  and  the  practical  experience  necessary  for 
each  group." 


TRAINING   OF    TEACHERS   FOR   OCCUPATIONAL   THERAPY. 


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TRAINING   OF    TEACHERS   FOE    OCCUPATIONAL   THERAPY,  23 

ORGANIZATION. 

This  country  is  confronted  with  the  task  of  preparing  teachers  for 
each  group  of  disabled  men.  Aside  from  invalid  occupations,  little 
attention  has  been  given  in  the  United  States  to  the  various  phases  of 
this  great  problem.  Not  only  are  few  teachers  available  to  start  the 
work  in  the  first  hospitals,  but  there  are  few  people  experienced  in 
the  preparation  of  such  teachers.  Some  hospitals  have  the  begin- 
nings  of  equipment  for  invalid  occupations  but  few  are  provided 
with  curative  workshops.  Furthermore,  this  country  has  no  back- 
ground of  experience  for  dealing  with  the  subject,  and  for  this  reason 
it  will  be  necessary  at  the  outset  to  resort  to  Canadian  hospitals  for 
observation  and  practice  work.  The  knowledge  of  the  allies  was 
gained  from  actual  experience  with  the  problem,  which  has  been 
costly  in  time,  money,  and  wasted  human  efficiency. 

Such  a  comprehensive  plan  as  is  demanded  by  the  present  emer- 
gency can  only  be  met  by  the  Federal  Government.  In  no  other  way 
can  a  uniform  standard  of  qualification  of  teachers  be  secured. 
Private  institutions,  with  their  inadequate  hospital  facilities,  school 
equipment,  and  lack  of  teaching  staff,  are  incapable  of  meeting  the 
situation.  Moreover,  since  these  institutions  will  be  under  the  direc- 
tion of  some  agency  of  the  Federal  Government  yet  to  be  determined, 
it  is  imperative  that  the  classes  preparing  teachers  of  disabled  men 
should  be  controlled,  directed,  and  supported  by  those  directing  their 
future  work. 

In  order  to  meet  the  difficulty  of  preparing  people  for  occupations 
that  are  not  at  the  present  time  followed  in  this  country,  the  principle 
should  be  asserted  that  these  people  will  be  trained  to  follow  a  voca- 
tion, and  that  that  vocation  is  the  teaching  of  the  handicapped. 
Every  principle  already  set  up  in  this  country — such  as,  for  example, 
those  established  under  the  Smith-Hughes  Act  with  regard  to  train- 
ing for  vocations — holds  true  for  the  training  of  teachers  of  disabled 
men. 

These  principles  of  vocational  education  are: 

(1)  Effective  preparation  for  a  vocation  requires,  first,  practice; 
second,  experience,  with  proper  theory. 

(2)  In  order  to  determine  what  shall  be  taught  persons  preparing 
for  any  vocation,  including  teaching,  the  demands  of  the  occupation 
are  the  first  consideration.     The  organization  of  the  work,  the  course 
of  study,  and  methods  employed  should  be  constantly  determined  and 
shaped  by  this  consideration.     Only  in  this  way  can  training  be  made 
direct  and  effective. 

(3)  In  any  scheme  of  training  for  a  vocation  every  requirement 
of  the  occupation  should  be  dealt  with  in  the  course.     This  may 
be  accomplished  either  by  setting  up  entrance  requirements  of  such 
a  character  as*  to  insure  that  the  student  already  possesses  a  certain 
amount  of  training.     This  means,  for  example,  that  if  it  be  deter- 
mined that  instructors  of  disabled  men  must  have  a  certain  amount 
of  manual,  industrial,  trade,  or  technical  skill  and  knowledge,  hos- 
pital observation  and  experience,  or  practical  experience  in  invalid 
occupations  or  curative  workshop ;  or  else  experience  in  the  vocational 
education  of  disabled  men,  together  with  an  elementary  knowledge 
of  the  medical,  mental,  economic,  and  sociological  problems  involved ; 


24  TRAINING   OF   TEACHERS  FOE   OCCUPATIONAL  THERAPY. 

then  this  training  must  either  be  given  in  the  course  or  as  much  of  it 
required  before  entrance  as  is  practicable.  In  order  to  accomplish 
results,  courses  which  are  short  must  necessarily  have  high  entrance 
requirements. 

(4)  It  is  a  well-founded  law  of  psychology  that  a  teacher  can  not 
successfully  confer  on  others  that  which  he  himself  has  never  ex- 
perienced. Vocational  education  the  world  over  has  come  to  rec- 
ognize that  instructors  of  vocations  must  themselves  be  experienced 
in  the  vocation  which  they  teach.  This  principle  has  been  written 
into  the  Federal  law.  It  is  recognized  by  every  agricultural  and 
mechanical  college  in  America,  and  by  every  private  and  public 
trade,  technical,  and  engineering  school.  Not  to  observe  it  would 
be  to  violate  a  quarter  of  a  century  of  experience  in  vocational  educa- 
tion gained  on  both  sides  of  the  Atlantic. 

Applied  to  the  teachers  of  disabled  men,  this  means  that  they 
must  be  persons  of  experience  in  the  subjects  which  they  teach,  and 
in  addition  possess  special  preparation  qualifying  them  to  meet  the 
particular  problem  of  the  handicapped  men.  The  first  task  confront- 
ing the  United  States  at  this  time  is  to  select  and  train  the  teachers 
of  teachers  of  disabled  men,  and  allow  them  practical  experience  in 
Canadian  hospitals. 

SELECTION    OF   INSTRUCTORS   FOR   INVALID   OCCUPATIONS. 

The  first  instructors  to  be  trained  should  be  carefully  selected  from 
the  standpoint  of  their  education,  previous  experience,  and  occupa- 
tional or  technical  knowledge.  They  should  be  chosen  with  the  idea 
that  they  are  to  become  directors  of  other  training  centers  established 
by  the  Federal  Government.  They  should  meet  as  far  as  possible  the 
different  entrance  requirements  for  teaching  the  various  groups  of 
men  as  outlined  in  the  chart  on  page  22. 

Teachers  of  invalid  occupations  and  simple  occupations  may  be 
found  who-  have  had  theoretical  training  and  practical  experience. 
Technical  and  skilled  instruction  is  not  so  much  needed  in  teaching 
invalid  occupations,  though  the  instruction  so  far  as  it  goes  should 
be  correct,  as  is  tact,  resourcefulness,  patience,  contact  with  the  sick 
and  a  knowledge  of  the  medical  problems  involved.  Before  such 
teachers  will  be  permitted  to  direct  the  work  of  invalid  occupations 
and  simple  occupations  in  the  first  Government  hospitals  for  the  dis- 
abled, or  to  train  other  teachers  for  teaching  the  disabled,  they  must 
qualify  in  a  short  intensive  course  of  not  more  than  four  weeks 
offered  by  the  Federal  Government. 

SELECTION  OF  INSTRUCTORS  FOR  OCCUPATIONAL  THERAPY. 

The  teachers  of  academic  subjects  of  an  elementary  nature  will 
be  found  in  the  ranks  of  educated  men  and  women,  especially  those 
who  have  had  teaching  experience.  A  course  of  four  weeks'  study 
of  the  medical  and  social  problems  involved  in  teaching  the  dis- 
abled soldiers,  together  with  practical  experience  in  teaching  the 
subnormal,  will  serve  as  preparation  for  this  group. 

Teachers  of  prevocational  and  vocational  subjects  in  the  curative 
workshops  may  be  recruited  from  manual  training  teachers,  from 
men  who  have  had  technical  knowledge  in  the  teaching  profession, 


TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL   THERAPY.  25 

and  from  the  ranks  of  skilled  workmen,  foremen,  and  superin- 
tendents who  are  quick  to  learn  and  have  developed  teaching  ability 
by  helping  their  fellows. 

Such  a  group  of  picked  men1  will  be  able  to  take  an  emergency 
course.  The  course  of  study  should  include  five  lectures  each  week, 
a  written  test  on  the  lectures  and  correlated  reading  on  some  phase 
of  the  problem  of  rehabilitation.  The  lecture  period  should  be  fol- 
lowed by  classroom  recitation  or  an  informal  discussion  of  the  sub- 
ject, including  the  reference  reading.  The  student  should  be 
required  to  keep  a  notebook  of  both  lectures  and  reading.  Each 
student  should  have  a  weekly  conference  with  the  instructor  and 
should  understand  thoroughly  the  corrections  on  the  written  test. 
The  final  examination,  weekly  tests,  notebooks,  and  recitations  should 
form  the  basis  for  marking. 

The  following  course  of  study  is  divided  into  weeks  according  to 
the  subjects  covered.  It  will  be  followed  by  practical  experience  in 
Canadian  military  hospitals. 

COURSE   OF   STUDY. 

I.  The  problem  of  rehabilitation. 

1.  Survey  of  problem  of  rehabilitation  from  the  wounding  in  the 
trench  to  placement  in  industry. 

2.  The  three  stages  of  rehabilitation :  Invalid  occupations,  occu- 
pational therapy,  and  vocational  education.    Function  and  scope  of 
each. 

-).  Medical,  social,  and  economic  problems  to  be  encountered  in 
rehabilitation. 

4.  Psychology  of  the  disabled  soldier. 

Discussion  and  reading  should  develop  the  point  of  view  neces- 
sary for  the  instructor.  The  reading  should  include  accounts  of 
rehabilitation  in  foreign  countries,  selected  chapters  from  One  Thou- 
sand Homeless  Men,  by  Solonberger;  Social  Service  in  Hospitals, 
by  Ida  Cannon;  and  The  Work  of  Our  Hands,  by  Herbert  J.  Hall. 

II.  Study  of  occupational  therapy  in  convalescent  cases  of  inters 
nal  diseases,  injuries,  and  postsurgical  treatment  (not  orthopedic). 

1.  Physiological  effect  of  muscular  activity  on  the  heart,  lungs, 
circulation,  digestion,  etc. 

2.  Important  points  in  the  medical  treatment  of  heart  trouble, 
tuberculosis,  and  common  diseases. 

3.  Relation  of  occupation  to  each  of  the  above  disabilities. 

4.  Relation  of  work  and  fatigue  and  indications  of  fatigue. 

Reading  should  include  references  from  Fatigue,  by  Mosso,  re- 
searches by  Prof.  Amar.  and  medical  authorities  on  various  diseases, 
etc. 

III.  Study  of  occupational  therapy  in  relation  to  orthopedic  treat- 
ment. 

1.  Physiology  and  anatomy  of  bones,  tendons,  muscles,  ligaments, 
and  peripheral  nerves. 

2.  Relation  of  occupational  therapy  to  orthopedic  surger}^  physio- 
therapy, mechano-therapeutics.  and  massage.     Danger  of  wrong  ex- 
ercise or  strain. 

1  "  Men  "  is  used  in  its  generic  sensr. 


26  TRAINING   OF    TEACHERS  FOR  OCCUPATIONAL   THERAPY. 

3.  Occupational    therapy    in    cases    of    amputations,    exercise    of 
stumps,  study  of  Amar  and  other  tests,  etc. 

4.  Value  of  exercise  in  reeducating  disused  and  stiffened  parts. 

5.  Exercise  in  spite  of  permanent  ankylosis-,  and  in  relation  to 
prosthetic  appliances. 

Reading:  References  from  the  American  Journal  of  Care  for 
Cripples,  from  Prof.  Amars  researches,  and  selections  from  medical 
journals. 

IV.  Study  of  occupational  therapy  in  mental  and  nervous  dis- 
orders. 

1.  Study  of  the  central  nervous  system. 

2.  Pathology  of  neuroses  and  psychoses. 

3.  St  udy  of  motor  functions  in  relation  to  nervous  system. 

4.  Effect  of  occupation,  fixing  the  attention,  interesting  the  patient, 
directing  channels  of  thought,  observing  methods  of  work  and  ways 
of  cooperating  with  the  physician. 

Reading:  References  from  Mental  Hygiene,  and  writings  of  Drs. 
J.  Madison  Taylor,  William  R.  Dunton,  jr.,  Herbert  J.  Hall,  Thomas 
AY.  Salmon,  etc. 

V.  Technique  of  occupational  therapy. 

1.  How  to  relax,  stimulate,  and  coordinate  the  brain;  how  to  con- 
centrate the  mind;  how  to  restore  self-confidence  and  overcome  de- 
pression, indifference,  and  excitability, 

2.  General  exercises,  exercise  of  certain  parts,  and  kinesiology. 
In   addition  to  reading   from  selected   medical   authorities,   the 

student  must  prepare  a  list  of  processes  from  agricultural  or  com- 
mercial or  industrial  pursuits  which  may  be  suitable  for  relaxing, 
stimulating,  coordinating,  or  concentrating  the  mind,  and  which 
may  be  used  to  restore  self-confidence,  overcome  depression,  indiffer- 
ence, and  excitability.  The  student  must  select  processes  from  one 
of  the  a^ove  pursuits  which  will  serve  for  general  exercise  and  for 
exercise  of  special  parts. 

VI.  Study  of  occupations  in  relation  to  occupational  therapy. 

1.  Analysis  of  industrial,  commercial,  and  agricultural  occupa- 
tions in  terms  of  therapeutic  values. 

2.  Modification  of  processes,,  special  devices  and  tools  for  special 
needs  and  fatigue  prevention. 

The  student  must  list  common  occupations  in  agricultural,  com- 
mercial, and  industrial  pursuits,  with  reference  to  those  occupations 
particularly  suitable  for  various  disabilities  and  combinations  of  dis- 
abilities, with  possible  machine  devices  and  tool  modifications  for 
handicaps. 

VII.  Methods  of  teaching. 

1.  Principles  involved  in  teaching  handicapped  persons  and  dis- 
abled soldiers. 

2.  Methods  of  presenting  processes  and  occupations. 

3.  Discipline  and  control  of  patients  in  curative  workshops. 

The  student  should  be  given  imaginary  cases  of  disabilities  with 
physician's  instruction  for  treatment  and  the  description  of  the 
patient's  education  and  experience,  From  this  he  must  present  a 
plan  for  occupational  treatment,  following  the  physician's  instruc- 
tion, and  developing  the  patient  toward  the  vocation  suggested  by 
the  vocational  expert.  The  student  must  show  not  only  the  patient's 


TRAINING  OF   TEACHERS  FOR  OCCUPATIONAL  THERAPY.  27 

-4 

occupation  in  the  curative  workshop  but  the  method  of  presentation 
and  development  of  instruction.  These  should  furnish  subjects  for 
class  discussion. 

VIII.  The  curative  workshop. 

1.  Equipment,  upkeep,  management,  record  keeping,  and  account- 
ing. 

2.  Physiological  value  of  occupational  therapy. 

3.  Psychological  value  of  occupational  therapy. 

The  student  should  list  equipment  for  different  curative  workshops 
and  show  diagrams  of  arrangement  and  prepare  sample  work  charts, 

As  the  continued  flow  of  returning  men  necessitates  additional 
instructors  they  may  be  recruited  from  the  ranks  of  the  disabled  men 
themselves.  There  will  be  among  the  patients  men  with  previous 
technical  experience  who  have  shown  marked  capacity  in  the  curative 
workshop  and  who  possess  teaching  ability.  These  will  make  the 
ablest  instructors,  provided  they  fulfill  the  "requirements  of  teachers 
of  occupational  therapy.  They  understand  more  clearly  than  a 
civilian  instructor  the  point  of  view  of  the  returned  man.  The  ex- 
ample, moreover,  of  one  who  has  himself  successfully  passed  through 
the  experience  of  war  and  has  overcome  a  handicap  is  a  constant 
source  of  encouragement  to  the  student  patients.  It  has  been  said 
that  no  one  better  than  a  inutile  can  train  a  mutile.  While  a  handi- 
cap overcome  is  a  definite  asset  to  a  teacher  of  disabled  men,  and 
while  many  of  the  handicapped  will  undobutedly  become  teachers,  a 
handicap  must  not  be  regarded  as  an  asset  offsetting  other  indispen- 
sable qualifications  for  an  efficient  teacher  and  leader  of  men. 

The  French  method  of  using  the  reconstruction  hospitals  as  train- 
ing centers  for  instructors  may  be  adopted  with  profit.  The  emer- 
gency course  as  outlined  for  the  first  instructors  for  returned  soldiers 
may "  be  modified  in  the  new  training  centers  and  many  theoretical 
points  abandoned  for  actual  practice  teaching. 

Before  competently  trained  people  will  engage  in  this  profession, 
and  especially  in  the  present  war  emergency,  they  must  be  assured 
adequate  remuneration. 

Mr.  L.  G.  Brock,  in  telling  of  the  importance  of  adequate  teachers 
for  the  convalescent  hospitals  of  France,  says : 

It  follows,  of  course,  that  if  great  demands  are  to  be  made  on  the  instructors 
they  must  be  carefully  selected  and  adequately  paid.  The  best  possible  men 
must  be  secured  without  regard  to  cost,  and  those  who  fail  to  develop  the  requi- 
site qualities  must  be  vigorously  weeded  out. 

QUALIFICATIONS  OF  TEACHERS  FOR  DIRECTING  OCCUPA- 
TIONAL THERAPY. 

The  courses  of  training  as  outlined  are  emergency  courses  only,  de- 
signed to  relieve  the  shortage  of  occupational  teachers  for  the  men 
who  will  return  disabled  from  the  front.  The  courses  do  not  attempt 
to  meet  the  problem  of  providing  occupational  therapy  for  civilian 
handicapped  persons,  who  will  in  all  probability  outnumber  the  war 
victims  by  a  large  majority.  Such  training  can  best  be  provided  in 
institutions  offering  long  and  thorough  courses. 

Since  occupational  therapy  dovetails  in  many  cases  with  medical 
treatment  and  either  vocational  training  or  employment,  it  is  funda- 
mentally necessary  for  the  occupational  therapeutist  to  have  a  back- 
ground of  both  medicine  and  industry  besides  the  actual  knowledge 


28  TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL  THERAPY. 

and  technique  of  the  profession.  Many  of  the  failures  of  occupational 
therapy  in  the  past  may  be  attributed  to  the  fact  that  it  has  been 
attempted  by  those  equipped  with  a  background  of  only  medicine  or 
industry.  This  accounts  for  the  lack  of  shop  management  and  prac- 
tical training  when  occupational  therapy  is  directed  by  doctor  or 
nurse;  and  equally  for  the  lack  of  the  patient's  interest  or  therapeutic 
results  when  directed  by  a  technical  expert.  The  medical  aspect  of 
the  problem  is  skillfully  manipulated  in  the  hands  of  the  doctor  or 
nurse,  but  they  are  usually  ignorant  of  the  variety  of  industrial  proc- 
esses, the  demands  of  competition,  and  the  economic  conditions  to 
which  the  patient  must  adjust  him,self.  The  shop  boss  or  tech- 
nician, on  the  other  hand,  fails  to  understand  the  connection  between 
physical  debility  and  impaired  capacity.  However  well  his  shop 
may  be  organized  or  however  expert  his  skill,  he  will  fail  utterly  with 
the  handicapped  unless  he  has  a  medical  and  social  background,  an 
intelligent  sympathy,  and  an  understanding  of  the  psychology  of  the 
handicapped. 

An  economic  background  is  as  essential  for  the  occupational  thera- 
peutist as  a  medical  and  industrial  background.  He  must  know  the 
relative  value  of  commodities,  how  to  effect  economies  in  purchasing, 
the  danger  of  an  over-stimulated  market,  what  markets  are  de- 
pendent upon  fads,  or  the  fickleness  of  the  public.  The  danger  of 
turning  men  away  from  real  vocations  by  successful  but  .superficial 
results  in  the  curative  workships  may  be  thus  avoided. 

The  director  of  occupational  therapy  must  know  something  of 
several  occupations  so  that  he  may  have  a  variety  of  resources  with 
which  to  attract  the  patient's  attention.  He  must  have  a  first-hand 
and  thorough  acquaintance  with  at  least  one  industrial  occupation 
and  a  general  knowledge  of  several  others,  so  that  he,  if  the  unit  is 
sufficiently  large,  or  his  assistants  will  be  able  to  hold  the  patient's 
interest  and  develop  him  in  practical  lines  over  a  considerable  period 
of  time.  He  must  know  how  to  restore  self-confidence  in  the  dis-, 
couraged,  how  to  awaken  ambition  in  the  disheartened,  and  how  to 
develop  perseverance  in  the  restless.  Quick  results  are  necessary 
for  the  encouragement  of  some,  painstaking  accuracy  for  the  progress 
of  others.  The  therapeutic  value  of  a  process  is  gone  for  some  pa- 
tients the  moment  they  master  it,  and  recovery  is  measured  by  the 
systematic  change  from  process  to  process,  each  demanding  more 
initiative  or  concentration.  Continued  practice,  long  after  the  mas- 
tery of  the  process,  gives  to  other  patients  just  that  assurance  and 
self-reliance  necessary  for  recovery.  The  occupational  therapeutist 
must  know  the  functions  of  muscles,  how  they  may  be  exercised,  how 
the  brain  may  be  stimulated  or  relaxed,  and  how  the  coordination  of 
body  and  mind  may  be  produced. 

The  faculty  for  learning  among  the  mature  handicapped  is  slow; 
here  infinite  patience  is  required.  Overexertion  is  particularly  to 
be  guarded  against,  and  only  the  medical  authorities  should  de- 
termine at  what  point  it  is  safe  to  stimulate  and  force  the  patient. 
The  best  medical  treatment  may  be  nullified  by  strain  or  by  failure  to 
take  proper  exercise.  It  is,  therefore,  of  the  utmost  necessity  that 
occupational  therapy  be  in  the  hands  of  one  specially  trained  to 
understand  these  conditions  and  to  carry  out  intelligently  the  doc- 
tor's instructions.  Each  disability  has  its  particular  limitations, 
possibilities,  and  methods  of  adjustment.  The  occupational  thera- 


TRAINING  OF  TEACHERS   FOR  OCCUPATIONAL  THERAPY.  29 

peutist  must  be  familiar  with  these  as  well  us  with  the  types  of 
work  which  the  patients  will  be  able  to  perform  on  discharge,  and 
the  conditions  under  which  it  is  advisable  that  they  work.  The 
cardiacs,  for  instance,  must  not  be  subjected  to  sudden  muscular  ex- 
ertion, nor  the  tubercular  to  dust  and  fumes.  The  patients  must  bo, 
trained  for  those  vocations  in  which  their  disabilities  will  IDG  re- 
duced to  a  minimum  and  their  faculties  increased  to  the  maximum. 

There  is  at  present  no  standard  course  of  training  or  qualifications 
for  directors  of  occupational  therapy.  Several  institutions  give 
courses,  but  none  are  complete  or  adequate  as  training  centers.  Dr. 
William  Rush  Dunton,  jr.,  president  of  the  National  Society  for  the 
Promotion  of  Occupational  Therapy,  has  gathered  together  the  opin- 
ions of  those  best  qualified  to  speak  in  an  article  entitled  "  Training 
of  occupational  teachers  and  directors,"  published  in  the  Maryland 
Psychiatric  Quarterly  for  July,  1917.  The  consensus  of  opinion  is 
that  personality  is  the  first  qualification  of  a  teacher  or  ^director  of 
occupational  therapy.  The  peculiar  problems  involved  in  working 
with  the  handicapped  necessitate  force,  resourcefulness,  tact,  sym- 
pathy, and  courage,  and  these  can  not  be  acquired  in  any  course  of 
training,  however  elaborate.  Miss  Gunderson,  of  the  Bloomingdale 
Hospital,  has  said:  "The  successful  occupation  teacher  or  director 
owes  more  to  her  tact  and  personality  than  to  her  skill  in  crafts." 

While  personality  is  a  foremost  consideration  in  the  selection  of  a 
teacher  or  director,  it  can  not  compensate  for  either  lack  of  training 
or  technique.  Since  occupational  therapy  is  more  and  more  becoming 
a  part  of  hospital  equipment,  it  is  opening  a  new  profession,  and  one 
for  which  the  most  careful  training  is  necessary.  The  following 
course  is  suggested  for  the  training  of  directors. 

A  high-school  course  is  prerequisite.  The  course  requires  four 
years,  the  equivalent  of  two  years  of  college  and  two  years  of  dis- 
tinctly technical  study. 

The  time  of  the  first  two  years  is  equally  divided  between^  academic 
and  technical  subjects.  The  purpose  of  the  academic  subjects  is  to 
give  the  proper  background  for  the  more  technical  work.  These 
subjects  include  chemistry,  physiology,  anatomy,  English,  and  eco- 
nomics. Physics  and  geometry  must  be  elected,  if  not  offered  for  col- 
lege entrance.  The  technical  subjects  include  mechanical  drawing, 
design,  and  crafts.  The  course  in  design  must  be  of  the  standard  re- 
quired for  training  professional  designers.  Xot  less  than  six  hours 
a  week  for  twro  years  is  required  in  design,  of  which  one  hour  is  a  lec- 
ture on  theory,  three  hours'  practice  in  abstract  designing,  and  two 
hours  in  practical  designing.  Six  hours  a  week  for  two  years  is  re- 
quired for  crafts.  The  first  year  includes  the  ^principles  of  several 
crafts — weaving,  willowT  .and  raffia  work,  stenciling,  block  printing, 
leather  work,  and  metal  work.  The  second  year  includes  a  detailed 
study  of  metal  work.  Metal  work  is  selected  because  it  holds  the 
greatest  number  of  possibilities  in  the  use  of  tools  and  processes,  and 
is  more  closely  connected  than  other  crafts  with  actual  mechanical 
operations.  The  work  includes  complicated  and  intricate  problems, 
so  that  the  student  may  acquire  skill,  touch,  and  technique,  and  the 
general  principles  of  hard  and  soft  soldering,  casting,  contraction, 
expansion,  and  annealing  of  metals,  forging,  and  electric  wiring. 

On  the  completion  of  the  first  two  years  the  student  has  a  back- 
ground and  a  technical  knowledge  of  design  and  craft.  The  purpose 


30  TRAINING  OF  TEACHERS  FOR  OCCUPATIONAL  THERAPY. 

of  the  following  two  years  is  to  provide  special  training  for  directing 
occupational  therapy.  One  semester  of  the  junior  year  should  be 
spent  either  as  a  volunteer  worker  under  a  competent  factory  inspec- 
tor, or,  better  still,  on  the  pay  roll  doing  factory  work  itself.  No 
part  of  the  student's  training  is  more  valuable  than  actual  knowledge 
of  lathes,  machinery,  quantity  and  quality  of  output,  and  industrial 
demands.  The  principles  of  the  woodworking,  metal,  and  building 
and  electrical  trades  should  be  studied  both  in  theory  and  practice. 
The  academic  subjects  required  for  the  remaining  semester  include 
psychology  and  sociology,  together  with  a  carefully  selected  list  of 
medical  reading  relating  to  cause  and  effect,  diagnosis,  prognosis,  and 
the  special  treatment  of  the  most  frequent  disabilities  with  which  the 
student  will  come  in  contact. 

It  is  assumed  that  the  student  has  already  mastered  the  principles 
of  design  and  is  ready  in  the  junior  semester  for  a  course  in  com- 
mercial design.  The  emphasis  in  the  crafts  is  upon  the  making  of  a 
marketable  product,  the  study  of  costs,  overhead  expense,  economy  of 
purchases,  shop  management,  and  utilization  of  waste  products.  The 
principles  involved  in  commercial  education  are  surveyed  and  re- 
ord  and  bookkeeping  are  also  studied  in  detail.  One  or  two  half 
days  weekly  in  the  semester  are  spent  as  a  volunteer  worker  in  the 
social-service  department  of  a  city  hospital.  The  student  receives  his 
first  contact  with  hospital  patients  under  direction,  and  he  becomes 
acquainted  with  their  problems  and  methods  of  solution.  It  is  desir- 
able that  he  find  employment  for  some  of  these  patients,  so  that  he 
may  have  the  experience  of  approaching  employers,  encountering 
the  difficulties  of  placing  these  people,  and  learning  the  tact  and  com- 
mon sense  necessary  in  the  "  follow  work." 

At  the  close  of  the  third  year  the  student's  theoretical  and  practical 
background  is  complete.  He  has  an  economic  perspective,  a  first- 
hand knowledge  of  industry,  a  medical  understanding  of  the  relation 
between  pathological  conditions  and  impaired  capacity,  and  has  had 
personal  contact  with  the  subnormal.  He  has  a  knowledge  of  com- 
mercial design  and  of  the  tools  and  processes  not  only  in  hand  but  in 
machine  industries  as  well. 

The  first  semester  of  the  fourth  year  gives  the  opportunity  for  the 
study  of  pedagogy  and  for  more  medical  reading,  with  special  study 
of  fatigue,  function  of  regulated  activity,  and  the  mechanism  of  re- 
covery through  the  psychology  of  occupation.  The  purpose  is  not  to 
give  the  student  sufficient  medical  knowledge  to  enable  him  to  deter- 
mine the  treatment  by  occupation,  but  to  enable  him  to  carry  out  in- 
structions intelligently  and  to  cooperate  in  securing  the  results  the 
doctor  wishes  achieved. 

"  The  physician  may  prescribe  occupation  in  a  somewhat  general 
sense,  as,  indeed,  he  might  prescribe  in  the  diet  more  protein  and  less 
carbohydrate ;  the  decision  as  to  whether  it  shall  mean  a  dropped  egg 
or  a  bit  of  beefsteak,  less  potato  or  less  toasted  bread,  falls  more 
naturally  to  the  province  of  the  nurse."1 

While  the  doctor  may  recommend  a  sedative,  or  a  stimulating  occu- 
pation, or  active  exercise  for  certain  stiffened  joints,  it  is  left  to  the 
skilled  occupational  therapeutist  to  decide  whether  the  desired  results 

1  Invalid  Occupations,  by  Susan  E.  Tracy. 


TRAINING  OF  TEACHERS  FOR  OCCUPATIONAL  THERAPY.  31 

will  be  best  accomplished  and  best  suited  to  the  vocational  needs  of 
the  patient  by  typewriting,  motor  mechanics,  drafting,  planning,  or 
agriculture. 

The  emphasis  in  design  and  crafts  in  the  senior  year  lies  in  methods 
of  teaching  rather  than  in  technical  proficiency.  The  last  semester 
of  the  fourth  year  is  reserved  for  practice  teaching  under  the  direc- 
tion of  an  experienced  occupational  therapeutist. 

Such  a  course  as  outlined  suggests  ideal  conditions  in  its  cooper- 
ation with  factory  inspector  and  the  hospital  departments  of  social 
service  and  occupational  therapy.  If  such  conditions  do  not  exist, 
the  course  of  study  might  be  shortened  to  three  years  and  the  student 
required  to  have  some  teaching  and  factory  experience  before  becom- 
ing a  director.  The  course  might  be  shortened  still  further  to  ad- 
vantage provided  the  student  has  knowledge  of  the  type  of  institu- 
tion and  patients  with  which  he  would  come  in  contact. 

For  instance,  it  would  not  be  necessary  for  the  student  to  have  a 
knowledge  of  factory  processes  and  industry  if  his  patients  are  in  a 
private  sanitarium  recruited  from  the  leisure  or  professional  classes. 
On  the  other  hand,  if  his  patients  belong  to  the  working  classes,  and 
come  from  the  farm,  the  skilled  or  the  unskilled  trades,  he  might 
eliminate  the  design  and  crafts  from  his  course  of  training  and 
specialize  more  particularly  on  the  therapeutic  effect  of  industrial 
occupations  and  vocational  education.  A  student  already  possessing 
technical  knowledge  or  medical  knowledge  would  be  able  to  shorten 
the  above  course  to  a  large  extent. 

Both  men  and  women  may  become  expert  directors  and  assistants 
of  occupational  therapy.  When  classes  are  separated  it  is  desirable 
that  women  teach  women  and  men  teach  men.  When,  however,  occu- 
pational therapy  is  given  to  really  sick  men,  as  occurs  in  many  in- 
stances, women  with  the  natural  ability  of  the  nurse  have  been  found 
to  make  the  ablest  instructors.  When  men  are  able  to  follow  a  fairly 
regular  course,  and  especially  when  it  has  a  technical  value,  it  is 
expedient  that  the  instruction  be  given  by  men  who  are  proficient  in 
their  lines. 

Such  a  general  course  as  outlined  would  necessarily  prepare  the 
student  to  be  a  jack-of -all-trades.  This  is  desirable  in  the  case  of 
training  of  the  occupational  therapeutist  who  is  unassisted  and  who 
must  offer  a  wide  range -of  activities.  It  is  equally  desirable  in  the 
training  of  the  director  of  occupational  therapy  of  a  unit  sufficiently 
large  to  include  several  assistants.  The  assistants  should  have  spe- 
cialized training  in  different  lines.  While  they  should  be  familiar 
with  the  kind  of  instruction  necessary  for  the  subnormal,  they  do  not 
require  the  wide  background  described  in  the  course  of  training  for 
directors.  Assistants  may  be  recruited  from  the  ranks  of  competent 
nurses  with  a  knowledge  of  tools,  or  technicians  with  a  knowledge  of 
the  problems  involved  in  teaching  the  handicapped. 

QUALIFICATIONS  OF  TEACHERS  FOR  VOCATIONAL,  EDUCATION. 

Ill  addition  to  the  requirements  of  the  regular  vocational  instruc- 
tor, the  instructor  of  the  disabled  soldier  must  know  those  points  in 
which  his  soldier  pupils  will  be  different  from  the  normal  pupils  to 
which  he  is  accustomed.  The  shop  instructor,  even  more  than  the 
instructor  of  related  or  academic  subjects,  must  be  highly  skilled  in 


32  TRAIXIXG  OF  TEACHERS  FOR  OCCUPATIONAL  THERAPY. 

his  trade  for  the  reason  that  many  of  the  men  will  have  had  experi- 
ence in  that  trade  and  that,  unlike  the  raw  youth  in  vocational  classes, 
they  will  be  critical  and  unwilling  to  learn  from  one  not  markedly 
their  superior.  As  a  rule,  the  boys  of  vocational  education  age  are 
eager,  quick,  and  teachable,  whereas  many  of  the  returned  soldiers, 
though  young  enough  to  have  receptive  minds,  are  of  maturer  age. 
The  fact  that  they  have  been  returned  unfit  for  further  military  serv- 
ice indicates  that  in  some  way,  either  by  lessened  vitality  or  perma- 
nent handicap,  they  are  below  par.  Moreover,  the  experience  of  war 
has  been  a  mentally  paralyzing  experience  and  the  instructor  must 
be  patient  and  must  understand  his  pupil.  In  addition  to  intelligent 
sympathy,  the  instructor  must  .maintain  regularity  and  meet  the 
requirements  of  the  vocational  school,  for  vocational  education  leads 
directly  to  employability.  The  patients  do  not  enter  the  vocational 
classes  until  the  medical  authorities  have  discharged  them  or  else 
state  that  their  physical  condition  will  permit  a  regular  course  of 
study. 

The  duty  of  the  instructor,  aside  from  giving  the  technical  infor- 
mation, is  to  take  the  patients,  after  their  periods  of  convalescence, 
in  which  the  demands  of  occupational  therapy  may  not  always  have 
been  as  stringent  as  desirable  and  prepare  them  to  meet  the  full  and 
regular  requirements  of  industry.  Inasmuch  as  up  to  the  time  of 
discharge  the  patients  have  been  more  or  less  constantly  under  mili- 
tary discipline,  and  since  they  must  enter  industry  as  civilians  the 
period  of  preparation  for  civilian  life  coincides  with  the  period  of 
vocational  education.  The  instructor  may  be  of  valuable  assistance 
during  this  trying  time  by  maintaining  a  discipline  in  the  school  that 
is  initiated  and  participated  in  by  the  patients  themselves.  He  must, 
moreover,  teach  them  to  be  self-reliant,  to  think  for  themselves,  to 
work  hard,  and  to  observe  hygienic  rules  of  living  which  are  self- 
imposed  rather  than  commanded  or  ordered. 

The  best  vocational  instructors  must  be  selected  for  training  the 
disabled  patients,  not  only  because  they  require  the  best  possible  in- 
struction but  because  the  problem  of  teaching  them  is  particularly 
difficult  and  important. 

EQUIPMENT. 

(a)  Invalid  occupations. — The  equipment  for  invalid  occupations 
is  necessarily  restricted  to  that  which  may  be  used  in  bed  or  a  chair, 
and  is  of  a  very  light  character.  Bed  tables,  slanting  desk,  and  a 
bed  bench  are  necessary.  The  slanting  desk  should  be  tilted  to  any 
angle  which  may  accommodate  the  restricted  positions  of  patients 
sustaining  fractures,  injuries,  and  deformities.  The  bed  bench  allows 
a  small  vise,  and  not  only  permits  many  occupations  otherwise  im- 
possible for  lack  of  the  strength  required  in  holding,  but  allows  oc- 
cupations for  the  one-armed. 

The  occupations  possible  cover  a  wide  range,  depending  upon  the 
patient's  education  and  inclination.  A  typewriter  will  enable  those 
patients  who  have  become  blinded  or  who  have  lost  the  use  of  their 
right  hand  to  write  letters  to  their  friends,  pass  the  time,  and  exercise 
stiffened  fingers.  Typewriting  is  an  occupation  of  interest  and 
profit.  Other  patients  will  be  interested  in  the  elementary  principles 
of  bookkeeping,  salesmanship,  mechanical  drawing,  mathematics,  etc., 


TRAINING  OF  TEACHERS   FOB  OCCUPATIONAL  THERAPY.  33 

while  those  without  a  rudimentary  education  may  be  benefited  by 
learning  to  read,  write,  and  figure.  Whittling,  bookkeeping,  net  and 
hammock  making,  leather  work,  and  other  light  work  requiring  such 
equipment  as  small  looms,  hammer,  pliers,  paste,  scissors,  knives, 
raffia,  twine,  rules,  paper  cutters,  letter  presses,  etc.,  are  practical  for 
invalid  occupations. 

(b)  Occupational  therapy. — Crafts,  commercial  training,  educa- 
tion, and  drafting  require  only  a  small  outlay  of  equipment.  As  oc- 
cupational therapy,  however,  attempts  to  give  training  of  a  practical 
type  and  to  provide  vocational  education  wherever  possible  in  the 
trades,  the  equipment  must  permit  at  least  the  elementary  stages  of 
such  training.  The  average  small  hospital  will  not  be  able  to  afford 
either  an  elaborate  or  extensive  equipment  for  this  purpose.  In  fact, 
even  technical  schools,  with  a  variety  of  equipment,  are  not  always 
able  to  teach  all  of  the  skilled  trades,  and  the  student  must,  in  many 
instances,  get  his  final  instruction  in  the  factory  itself.  Elementary 
processes,  foundation  work,  and  related  subjects  may  be  selected  for 
trade  training  for  the  hospital  unable  to  provide  an  extensive  equip- 
ment. Simple  processes,  with  a  theoretical  knowledge  and  an  im- 
proved general  education,  are  of  practical  value. 

The  problem  of  equipment  is  simplified  in  large  county  or  State 
institutions.  Not  only  is  a  large  equipment  needed  to  accommodate 
the  patients,  but  the  institution  may  economically  afford  to  specialize 
in  one  or  more  industries  giving  real  trade  training  and  finding  a 
market  in  other  institutions  as  well  as  providing  necessities  for  the 
institution  itself.  The  repair  and  upkeep  of  a  group  of  large  institu- 
tions  under  direction  furnish  valuable  training.  Besides  the  oppor- 
tunity of  a  possible  machine  shop,  woodworking  shop,  farm,  and  care 
of  building  and  motor  trucks,  printing  may  not  only  teach  the  essen- 
tials of  the  printing  trade,  but  provide  the  printing  of  all  record 
blanks,  notices,  reports,  etc.,  for  the  hospital,  as  well  as  the  printing 
of  other  county  or  State  material. 

Since  the  reconstruction  hospitals  will  be  located  in  different  sec- 
tions of  the  country  and  the  patients  will  be  sent  to  the  hospitals  suited 
to  their  needs  nearest  their  homes,  it  will  not  be  necessary  to  install 
all  lines  of  occupations  in  industry,  commerce,  and  agriculture  in 
every  hospital.  For  instance,  the  hospital  in  the  Middle  West  would 
need  agricultural  opportunities  rather  than  the  textile  trades  of  New 
England.  Those  occupations  should  be  taught  which  are  typical  in 
the  area  to  whicji  the  patients  will  return.  Moreover,  it  is  advisable 
to  separate  the  patients  according  as  their  disabilities  require  special 
medical  and  occupational  treatment.  For  instance,  the  blind  are 
grouped  together  so  that  they  may  have  the  benefit  of  skilled  oph- 
thalmologists and  the  instruction  of  those  specially  trained  for  teach- 
ing the  blind.  They  will,  moreover,  be  taught  only  those  occupations 
which  it  is  practical  for  the  blind  to  follow.  The  same  is  true  of  the 
deaf  and  the  tubercular.  It  is  desirable  that  the  tubercular  and 
gassed  patients  should  have  work  of  a  light  character,  free  from  dust 
and  fumes,  and  requiring  deep  breathing.  Out-of-door  work  can  be 
found  for  cured  tubercular  patients  in  rural  communities  or  for  those 
who  wish  to  go  to  the  land,  while  light  work  out  of  doors  or  in  well- 
ventilated  factories  and  offices  may  be  secured  for  city  patients. 
Only  those  industries  which  exist  in  a  given  area  and  which  are  suit- 

42298°— S.  Doc.  167, 65-2 3 


34  TRAILING  OF  TEACHERS  FOB  OCCUPATIONAL  THERAPY. 

able  for  orthopedic  patients,  or  which  are  capable  of  modification, 
need  be  offered  in  the  orthopedic  curative  workshop.  Cases  of  neu- 
rasthenia, shell  shock,  and  insanity  should  not  only  be  separated  from 
other  cases,  but  from  one  another.  Inasmuch  as  complicated  and 
noisy  machinery  and  intricate  processes  are  not  adapted  to  neuras- 
thenic or  shell-shock  cases,  the  equipment  for  these  curative  work- 
shops may  be  comparatively  simple,  including  gardening  and  outdoor 
work,  hand  industries,  drafting,  blue-print  making,  general  educa- 
tion, and  only  elementary  stages  in  shopwork.  Hopeless  insanity 
may  be  provided  for  in  the  regular  asylums.  The  general  hospital 
would  have  to  provide  the  greatest  range  of  equipment  in  its  curative- 
workshop,  but  it  could  be  limited  to  the  industries  in  the  district  and 
omit  those  occupations  particularly  suited  to  the  blind,  deaf,  tuber- 
cular, etc. 

The  upkeep  of  the  reconstruction  hospitals,  all  repairs,  carpentry, 
glazing,  plumbing,  machine  work,  driving,  care  of  motor  trucks  and 
gardens  should  be  performed  by  the  patients  under  direction  as  part 
of  the  course  of  training. 

The  responsibility  of  the  Government  to  provide  practical  occupa- 
tional therapy  for  the  returning  of  the  men  to  the  industries  from 
which  they  were  taken  will  necessitate  equipment  suited  to  the  pur- 
poses and  needs  for  training  the  disabled  soldiers  in  the  curative 
workshop.  The  problem  of  equipping  the  curative  workshop  is 
unlike  the  problem  of  equipping  the  private,  the  county,  or  State 
institutions,  where  the  outlay  in  expense  must  be  considered  in  rela- 
tion to  possible  returns  from  the  shop,  and  where  many  of  the 
patients,  while  benefited  by  occupational  therapy,  will  never  be  able 
to  follow  wage-earning  occupations.  Unlike  many  of  the  patients 
in  these  public  institutions,  the  majority  of  the  disabled  soldiers  will 
be  able  to  follow  wage-earning  occupations,  provided  that  the  occu- 
pational therapy  designed  for  them  is  immediate  and  practical.  It 
is  a  far-sighted  economy  to  return  men  to  industry  by  training 
them  to  be  self -supporting  and  independent  economic  units,  and  to 
attain  this  end  the  Federal  Government  is  justified  in  making  a 
large  expenditure  for  the  equipment  of  the  curative  workshop.  The 
problem  of  equipping  the  curative  workshop  becomes  then  one  of 
intelligent  expenditure  and  cooperation  with  other  Federal  agencies, 
so  that  the  equipment  may  provide  practical  training  in  itself  or 
else  be  of  such  a  type  as  to  prepare  for  subsequent  vocational  or 
factory  training,  which  in  turn  prepares  for  employment. 


PART  II. 
FUNCTIONS  OF  OCCUPATIONAL  THERAPY. 

It  has  been  long  known  that  treatment  by  occupation  has  a  definite 
therapeutic  value.  Originally  the  benefit  was  supposed  to  be  due 
entirely  to  the  fact  that  such  treatment  "  killed  time "  for  the 
patient,  but  later  it  was  found  to  have  a  definite  effect  on  the  mind 
and  spirit,  and  consequently  a  favorable  reaction  on  the  physical 
condition.  It  was  frequently  observed  that,  while  the  patient's  mind 
was  absorbed  in  mastering  an  occupation  in  the  hospital  workshop, 
his  interest  was  awakened,  his  ambition  stimulated,  his  morbid  and 
brooding  thoughts  eliminated,  and  his  hope  and  self-confidence  were 
restored.  More  recent  analysis  of  the  function  of  occupational 
therapy  discloses  the  fact  that,  in  addition  to  producing  mental 
changes,  it  may  also  impose  certain  bodily  changes. 

Although  the  fields  of  the  mind  and  the  body  are  fundamentally 
related,  occupational  therapy  may  be  considered  from  the  point  of 
view,  first,  of  psychological  functions  and,  second,  of  physiological 
functions. 

PSYCHOLOGICAL  FUNCTIONS. 

In  every  functional  disturbance,  in  addition  to  disorders  of  the 
central  nervous  system,  there  is  a  mental  reaction.  Pain,  anemia, 
impairment  of  circulation,  and  sense  impressions  and  emotions,  such 
as  anxiety  and  depression,  are  all  communicated  to  the  brain,  which 
may  be  either  highly  sensitive  or  dull  and  apathetic,  often  showing 
such  extreme  symptoms  as  ennui,  melancholia,  restlessness,  morbid 
introspection,  discouragement,  and  fear.  In  ennui  the  tonicity  of 
the  muscles  is  affected  so  that  they  actually  contract  less  strongly 
and  develop  less  force.  In  melancholia  the  general  physique,  and 
especially  the  heart,  is  acted  upon.  Restlessness,  or  so-called  nerv- 
ousness and  lack  of  concentration,  is  muscular  activity  of  a  wasteful 
type  and  gives  rise  to  harmful  fatigue.  Morbid  introspection  pro- 
duces a  particularly  vicious  cycle  of  thinking,  since  continued  atten- 
tion focussed  on  any  particular  part  of  the  body  may  actually  in- 
crease its  morbid  condition.  Discouragement  and  fear  have  a 
tendency  to  impair  circulation,  which  may  produce  serious  results 
upon  the  heart,  digestive  apparatus,  and  muscles. 

It  lies  within  the  province  of  occupational  therapy  to  regulate  and 
improve  some  of  these  conditions.  Ennui  and  melancholia,  for  ex- 
ample, may  give  place  to  a  more  normal  state  when  the  patient 
has  become  interested  in  an  occupation.  Inasmuch  as  those  who 
suffer  from  ennui  and  melancholia  are  particularly  susceptible  to 
fatigue,  the  occupation  chosen  for  their  cure  should  be  simple,  and 
the  treatment  should  be  given  in  short  periods  in  order  to  avoid 

35 


36  TRAILING   OF   TEACHERS  FOR  OCCUPATIONAL  THERAPY. 

undue  fatigue.  Variety  and  more  complicated  processes  are  neces- 
sary, however,  as  the  patient  improves,  and  gradually  the  treatment 
should  require  increasing  concentration.  Again,  restlessness,  nerv- 
ousness, and  lack  of  concentration  require  the  focussing  of  the 
attention  upon  constructive  work.  An  occupation  of  a  sedative  or 
relaxing  type  which  may  have  a  certain  degree  of  monotony  about 
it  which  is  not  exacting  and  which  may  be  pursued  for  long  periods 
of  time  has  a  tendency  to  normalize.  For  the  morbidly  introspective 
patient  an  occupation  must  be  selected  which  will  turn  away  his 
accustomed  line  of  thinking  and  at  the  same  time  offer  sufficient  inter- 
est and  variety  to  hold  his  attention.  Recovery  may  frequently  be 
measured  by  the  greater  complexity  of  occupations  undertaken, 
each  demanding  greater  application  than  the  one  before  it.  Dis- 
couragement and  fear  may  be  overcome  by  a  simple  or  monotonous 
occupation,  provided  the  patient  masters  it  and  continues  to  perform 
it  with  satisfaction  to  himself  and  with  growing  self-confidence  and 
hope. 

The  mechanism  of  mental  recovery  by  occupational  therapy  is 
simple.  "  But  one  idea  can  occupy  the  focus  of  attention  at  a  given 
time." *  In  other  words,  an  occupation  which  requires  the  patient's 
attention  excludes,  at  least  temporarily,  all  harmful  thoughts.  As 
Dr.  J.  Madison  Taylor  has  pointed  out : 

It  is  to  the  last  degree  unfortunate  for  the  patient  if  suitable  conditions  are 
not  provided  with  outlets  for  energies  until  evil  mental  habits  have  continued 
beyond  the  stagnation  point  where  they  may  be  radically  corrected. 

All  persons  are  subject  to  variations  in  self-control,  to  ups  and  downs  of 
<  iHTgy,  impulse,  emotion,  action,  judgment. 

Some  minds  are  inherently  well  poised,  but  most  have  suffered  greater  or 
less  derangement  in  normal  responsiveness  to  external  and  internal  impres- 
sions. There  is  then  disharmony  between  receptibility,  interpretation,  impulse, 
and  determination. 

Such  a  disharmony  leads  to  many  complications  but  may  be  cor- 
rected if  "  volition  can  be  made  to  precede  action "  and  "  decision 
and  action  made  clear  and  enforced."  Properly  directed  occupation 
can  do  much  toward  developing  volition  and  its  proper  execution. 
It  may,  for  instance,  stimulate  an  idea. 

In  some  persons  ideas  spring  to  life  in  profusion,  in  perfection,  and  in- 
stantaneously; others  require  much  time,  and  then  ideation  is  often  unclear. 
Training  can  do  much  to  enhance  or  retard.3 

The  idea  or  sensation  has  a  natural  desire  to  express  itself  in 
action. 

If  there  be  no  image  there  will  be  no  concept,  and  no  concept  can  be  formed 
without  an  accompanying  motor  outflow.2 

It  is  the  task  of  the  occupational  therapeutists  to  direct  this 
motor  outflow  so  that  indecision,  doubt,  and  fear  do  not  prevent  the 
logical  execution  of  the  idea.  Execution  may  be  guided  during  the 
performance  of  the  occupation.  As  the  patient  progresses  he  should 
be  given  occupations  demanding  more  intricate  and  difficult  mental 
processes  and  requiring  more  rythmic,  accurate,  and  deliberate 
physical  movements. 

1  Occxipntipnal  Therapy,  by  William  Rush  Dunton,  jr.,  instructor  in  psychiatry,  Johns 

2PDr?SJ.  Madison  Taylor.  Psychic  Hypertension  :  Restoration  of  Mind  Control  by 
Motor  Training  in  Relaxation.  International  Clinics,  Vol.  II,  series  22,  1912. 


TRAINING    OF    TEACHERS   FOR   OCCUPATIONAL   THERAPY.  37 

Muscular  energy  is  so  closely  associated  with  tlie  integrity  of  neurons  that 
all  influences  affecting  them  become  of  extreme  significance,  whether  bearing 
upon  mental  or  physical  competency.  Right  habit  formation  is  based  on  right 
guiding  in  motor  impulses,  and  is  essential  to  right  thinking.  *  *  *  Per- 
haps in  time  mankind  will  learn  that  exercise  is  a  normal  and  needed  use  of 
motor  machinery,  developmental,  educational,  or  reparative.1 

Muscular  training  and  the  development  of  the  entire  motor  forces 
in  action  may  be  carried  on  by  properly  prescribed  and  conducted 
occupations  for  "  work  is  the  product  of  action,  good  work,  of 
normality  in  the  sum  of  actions."  1 

The  mental  poise,  control,  optimism,  and  activity  thus  newly  ac- 
quired reacts  favorably  upon  the  entire  body  and  facilitates  recovery 
by  assisting  in  such  of  ^the  functions  of  life  as  nourishment,  the  pro- 
duction of  digestive  juices,  and  the  cycle  of  metabolism.  Prof. 
Amar 2  has  noted  in  this  connection  that  soldiers  who  have  per- 
formed some  praiseworthy  act  and  are  consequently  happy  recover 
rapidly  from  their  wounds. 

Amroise  Pare,  the  great  French  surgeon  of  the  sixteenth  century, 
went  so  far  as  to  say  "  the  happy  always  recover."  However  exag- 
gerated this  statement  may  be,  the  fact  is  significant  that  contentment 
reacts  favorably  upon  the  entire  physical  system  and  that  sadness  or 
worry  produces  a  condition  characterized  by  muscular-nervous  de- 
pression, inhibition,  retarded  respiration,  and  enfeebled  heart  and 
circulation. 

PHYSIOLOGICAL  FUNCTIONS. 

Physical  recovery  is  measured  by  the  growing  muscular  power  of 
the  patient,  his  coordination,  and  his  resistance  to  fatigue.  Neither 
of  these  can  be  acquired  suddenly ;  they  must  be  developed  by  gradu- 
ated activity. 

Muscular  exercise  affords  varied  and  valuable  fields  of  usefulness. 
It  relieves  the  heart  by  emptying  the  veins ;  it  replaces  fat  by  muscle, 
and  thereby  prevents  the  stagnation  of  blood  and  lymph  in  tissue 
which  does  not  spontaneously  expel  it;  it  increases  oxygenation  of 
cells  and  tissues ;  and  it  enhances  digestion  and  metabolism. 

Activity  is  essential  to  health;  it  is  necessary  in  rebuilding  tissues 
and  in  the  process  of  recovery.  Dr.  Taylor,  in  his  Remarks  on  the 
Treatment  of  Chronic  Disease,  goes  so  far  as  to  say : 

Much  can  be  achieved  by  bringing  into  line  the  functional  power  of  the  organs 
and  tissues  so  as  to  secure  the  completest  transformation  of  dynamic  into 
kinetic  energy  no  matter  what  the  morbid  agency. 

Health  and  recovery  depend  to  a  large  extent  upon  thoroughness 
of  oxygenation.  Faulty  oxygenation  results  in  accumulation  of  acids 
and  toxins.  While  respiration  is  the  basis  of  oxygenation,  the  mus- 
cular system  is  a  powerful  aid.  Muscular  activity  produces  deep 
breathing,  and  the  oxygen  acquired  through  the  lungs  and  consumed 
by  the  muscles  in  contraction  provides  natural  oxygenation  and  de- 
stroys acid  products. 

1  Dr.    J.    Madison    Taylor.     Psychic    Hypertension :    Restoration    of    Mind    Control    by 
Motor  Training  in  Relaxation.     International  Clinics,  Vol.  IT,  series  '22.  101± 

2  Direct eur  clu  Laboratoire  de  Recherches  sur  le  Travail  Professional  au  Conservatoire 
National  des  Arts  et  Metiers. 


38  TRAINING   OF   TEACHERS  FOR  OCCUPATIONAL   THERAPY. 

The  most  powerful  drugs  can  do  little  for  ultimate  restoration  of  capacity  if 
the  great  oxygenating  laboratories,  the  muscles,  cease  to  play  their  essential 
cooperative  part.1 

All  muscular  activity  is  registered  in  respiratory  functions.  The 
deeper  breath,  the  fuller  heart  beat,  the  quickened  circulation  are  true 
tonics.  The  problems  of  oxygenatioii  and  oxidation  can  be  made  sim- 
ple, and  can  be  applied  in  the  routine  of  daily  work.  For  these  rea- 
sons it  is  the  task  of  the  occupational  therapeutist  to  direct  the  ac- 
tivity of  the  patient  so  that  he  shall  benefit^by  the  exercise  of  his  oc- 
cupation, adapting  the  exertions  required  in  that  occupation  to  the 
patient's  changing  physical  condition. 

When  the  gain  in  strength  warrants  further  movements  of  the  arm,  trunk, 
neck,  and  legs,  they  can  be  employed  with  advantage,  measured  by  time  and 
forcefulness,  rather  than  by  the  number  and  variety  of  movements.1 

The  proper  activity  of  the  invalid  is  most  important,  for  the  reason 
that  his  endurance  is  limited,  easily  fatigued,  and  his  motor  ma- 
chinery tends  "to  lose  range,  scope,  elasticity,  and  nicety  of  ad- 
justment.'' 

After  acute  illness  there  follows  slower  oxidation     *     *     *    and  also,  partly 
as  a  consequence  of  this,  a  habit  of  mind  discouraging  energizing,  or  there 
may  follow  injudicious  impulses  to  action,  the  product  of  commendable 
yet  imperiling  tissues  far  from  stable  and  which  require  wise  training.1 

The  relation  of  activity  to  fatigue  is  fundamental ;  the  weaker  the 
patient  the  less  his  resistance  to  fatigue.  Great  care  must  be  exer- 
cised that  no  strain  falls  on  any  part,  for  the  body  is  no  strc 
than  its  weakest  organ,  and  too  great  or  prolonged  muscular  activity 
produces  sarcolacite  and  carbonic  acids  in  excess  of  oxidation,  which 
may  result  in  hyperacidity  and  subeatabolism. 

The  value  of  proper  activity  is  so  great  and  the  danger  of  over- 
doing or  doing  the  wrong  kind  of  thing  is  so  serious  that  no  patient 
should  undertake  any  kind  of  exercise  or  occupation  without  the 
order  of  the  physician.  The  exercise  should  then  be  directed  and 
'watched  by  one  skilled  in  this  particular  practice  and  trained  to 
note  signs  of  fatigue.  It  is  the  duty  of  the  occupation*!  thera- 
peutist to  restrain  feverish  and  excitable  attempts  on  the  part  of 
the  patient  or  to  strengthen  languid  motion,  and,  above  all,  to  carry 
out  the  doctor's  orders  intelligently. 

For  instance,  the  doctor  may  prescribe  certain  movements  of  the 
arms.  These  movements  may  be  accomplished  by  dumb-bell  exercises, 
but  they  can  be  made  far  more  effective  and  of  greater  interest  to 
the  patient  if  a  hammer,  plane,  or  saw  is  used  instead.  The  weight 
of  the  tool,  the  nature  of  the  material — iron,  copper,  etc.,  annealed 
or  tempered;  wood,  hard  or  soft — all  call  for  different  lands  of 
exercises  and  varying  degrees  of  energy.  Different  muscles  are 
used  in  planing  the  top  of  a  surface  from  those  used  in  planing  an 
under  surface  or  taking  off  an  edge.  The  patient  may  hold  his 
body  rigid,  using  only  the  muscles  of  his  arm  in  hammering  and 
expending  as  much  energy  on  the  down  stroke  of  the  hammer  as  in 
lifting  it  on  the  up  stroke.  In  such  a  case  relaxation,  bodily  rhythm, 
and  coordination  are  impossible,  and  the  arm  must  experience  unnec- 
essary strain  and  fatigue.  On  the  other  hand,  the  patient  may  stand 

1  Dr.  J.  Madison  Taylor.  Motor  Education  in  Convalescence  and  Invalided  States. 
Medicine,  September,  1905. 


TRAINING   OF   TEACHERS  FOR  OCCUPATIONAL  THERAPY.  39 

with  his  weight  on  his  left  leg,  provided  this  is  in  accordance  with 
his  physical  condition,  and  feel  the  impetus  from  the  ankle  or  toe 
of  his  right  foot  extend  through  and  coordinate  all  the  muscles  of 
his  body,  which  terminates  in  an  even  and  rhythmic  lifting  of  his 
right  arm.  The  hammer,  with  nicely  balanced  head  and  handle, 
allowing  vibration,  describes  an  arc  and  falls  of  its  own  weight 
with  a  blow  far  more  forceful  than  can  be  effected  by  using  strength 
on  the  downward  stroke,  and  thus  the  patient's  strength  is  conserved 
by  half. 

The  law  of  repose,  as  stated  by  Jules  Amar,  reads : 

The  muscle  returns  to  a  state  of  repose  in  proportion  to  the  speed  with  which 
it  was  exercised.1 

The  expenditure  of  energy  is  in  proportion  to  the  activity  of 
the  muscles,  in  relation  to  their  coordination  and  contractions  and 
the  intensity,  duration,  and  speed  of  their  movement.  All  these  fac- 
tors determine  the  degree  of  fatigue,  and  must  be  considered  in  any 
attempt  at  muscular  restoration. 

The  following  laws  of  Chauveau  may  be  noted  in  this  connection : x 

The  expenditure  of  energy  is  proportional  to  the  effort  of  the  contraction  of 
the  muscles,  to  the  duration  of  the  effort,  and  to  the  degree  of  muscular 
recovery. 

There  exists  the  correct  effort  and  speed  to  produce  the  maximum  work  with 
the  minimum  fatigue. 

Occupational  therapy  may  accomplish  a  general  toning  of  the 
heart,  lungs,  vasomotor  system;  increase  resistance  to  fatigue ;  develop 
physical  efficiency  by  intelligently  conserving  wasteful  energy;  exer- 
cise particular  parts  to  regain  their  functions;  train  sense  organs 
which  have  become  blunted  by  disorders  of  a  nerve  or  traumatic 
origin ;  and  improve  the  entire  psychic  condition  of  the  patient. 

INTERNAL    DISEASES,    INJURIES,    AND    POSTSURGICAL    TREATMENT    (NOT    ORTHOPEDIC). 

The  method  of  building  up  the  physique  and  of  increasing  re- 
sistance to  fatigue  necessarily  differs  for  different  types  of  dis- 
ability. After  eliminating  disorders  of  the  central  nervous  system, 
disabilities,  from  the  point  of  view  of  their  occupational  treatment, 
fall  into  two  main  classes — first,  internal  diseases  and  injuries;  and, 
second,  cases  requiring  orthopedic  treatment  or  surgery. 

The  most  frequent  disabilities  included  under  internal  diseases 
and  injuries  are  tuberculosis,  heart  trouble,  arteriosclerosis,  rheuma- 
tism, kidney  trouble,  and  general  debility  and  surgical  cases  not 
orthopedic.  The  occupational  treatment  of  each  of  these  disabilities 
has  many  points  in  common,  such  as  the  gradual  increase  of  nervous 
and  cardiac  tonicity  by  regulated  muscular  activity,  improved  mental 
condition,  and  avoidance  of  strain  and  fatigue.  The  doctor  must, 
of  course,  prescribe  the  kind  and  extent  of  the  exercise  in  each  case. 
There  are,  however,  a  few  important  points  to  be  considered  in  the 
occupational  treatment  of  certain  disabilities. 

For  instance,  the  emphasis  must  be  on  "graduated  labor"  in 
tuberculosis.  This  is  advocated  by  Dr.  M.  Patterson,  of  Frimly, 
England.  Progress  in  the  cure  of  tuberculosis  must  begin  with  com- 
plete rest,  necessary  to  check  the  disease,  though  ultimately  weaken- 
ing the  muscles  and  bodily  functions.  When  the  patient  is  up  and 

1  Translated  from  Organisation  Physiologique  du  Travail,  by  Jules  Amar. 


40  TRAINING    OF    TEACHERS   FOR   OCCUPATIONAL   THERAPY. 

begins  his  exercise  it  must  be  by  prescription *  of  the  doctor  and 
increased  from  as  short  a  period  as  15  minutes  once  a  day  to  30,  45 
minutes,  1  hour,  2  hours,  etc.,  till  the  patient  is  able  to  work  8  hours 
a  day  at  an  occupation  demanding  a  fair  degree  of  muscular  exertion. 
The  occupation  of  the  patient  should  be  selected  in  no  haphazzard 
way,  but  should  be  considered  in  the  light  of  his  future  employment. 
The  speed  with  which  he  may  increase  the  periods^of  his  exercise 
depends  upon  his  temperature,  pulse,  sputa  examination,  and  the  ob- 
servations of  the  physician.  A  work  chart  further  assists  the  physi- 
cian in  shoAving  the  patient's  methods  of  work,  reactions,  and  fatigue. 

u  Cured,  but  unfitted  for  labor,"  is  the  chronic  complaint  of 
tuberculosis  patients.  This  does  not  apply  to  those  patients  who 
have  received  occupational  treatment  during  convalescence.  With- 
out such  treatment  patients  not  infrequently  suffer  a  serious  recur- 
rence of  the  disease  upon  attempting  a  normal  day's  work  with 
muscles  weakened  by  long  disuse  in  the  sanitarium.  The  occupa- 
tions for  the  tubercular  should  necessarily  be  light,  requiring  deep 
breathing,  outdoors  if  possible,  or,  if  indoors,  in  a  well-ventilated 
room  of  even  temperature  and  free  from  fumes,  dust,  and  dampness. 

The  Association  for  the  Prevention  and  Relief  of  Heart  Disease  2 
states  that  more  people  die  from  heart  disease  in  New  York  City 
than  from  tuberculosis,  and  that  the  death  rate  from  heart  trouble 
is  steadily  increasing.  Vital  statistics  of  the  Census  Bureau  show 
that  heart  disease  is  one  of  the  three  diseases  causing  nearly  one- 
third  of  the  deaths  in  the  registration  area  of  the  United  States. 

Methods  of  treatment  for  heart  disease  are  undergoing  changes, 
but  a  proved  method  of  treatment  includes  exercise,  prescribed 
either  by  a  heart  specialist  or  by  one  who  has  had  wide  experience 
with  the  dangers,  difficulties,  and  complications  of  heart  disease. 
The  emphasis  in  the  occupational  treatment  of  heart  trouble,  like 
that  in  tuberculosis,  lies  in  the  graduation  of  the  exercise.  There  is 
no  disability  in  which  prevention  and  early  treatment  may  play  a 
more  decisive  part  than  in  heart  trouble.  Adequate  convalescence, 
graduated  exercise,  and  proper  occupation,  with  avoidance  of  sudden 
muscular  exertion,  may  prevent  heart  trouble  of  a  serious  and  hope- 
less type.3 

1  At   Mumlale   Tuberculosis    Sanitarium,   Milwaukee  County,   Wis.,   an   exercise   permit 
card  signed  by  the  physician  is  given  the  patient  when  he  is  able  to  go  to  the  work- 
shop.    It  has  been  found  to  be  a  matter  of  psychology  to  head  the  card  "  exercise  permit." 
The   patients    enter    more    enthusiastically    into    that    which    is    permitted    rather    than 
required.     On   a  bulletin   board   in   the  shop  is  posted   each  week   the   names   of  those 
patients  who  are  permitted  increased  working  hours.     The  patients  take  great  pride  in 
the  bulletin  board  and  post  items  of  interest,  such  as  work  of  patients  in  other  places, 
suggestions  of  articles  to  be  made,  etc.     The  bulletin  board  has  not  only  improved  the 
morale  in  the  workshop,  but  has  created  an  interest  and   spirit  throughout  the  entire 
sanitarium. 

2  The  Winifred  Masterson  Burke  Relief  Foundation  has  made  valuable   contributions 
to  the  study  of  convalescence,  not  the  least  of  which  has  been  the  convalescence  and 
treatment   of   cardiacs.      At   the   convalescent   home   maintained   by    the    foundation,    of 
which  Dr.  Frederic  Brush  is  superintendent,  800  patients  suffering  from  organic  heart 
disease  have  been  treated.     Many  of  them  have  returned  to  productiveness  after  a  record 
of  months  in  the  hospitals. 

3  The  1914  report  of  the  Social  Service  Bureau  of  Bellevue  and  Allied  Hospitals  shows 
that,  without  adequate  convalescence,  occupation,  and   suitable  work,   "  the  progress   of 
the  '  cardiac  '  is  a  downward  one  if  he  is  of  the  laboring  class.     His  latter  history  is 
usually  that  of  a  '  hospital  repeater '  and  dependent.     *     *     *     We  accept  his  decline 
to  misery  and  dependency  as  inevitable,  not  realizing  that,  even  from  the  economic  point 
of  view,  this  is  a  wasteful  attitude."     Medical  and  social  care  of  cardiacs  has  decreased 
the  time  spent  in  hospitals.     They  have  lessened  the  patient's  suffering,  lessened  expense, 
and  improved  industrial  efficiency.     A  record  of  6  cases   showed  that  251   days,  or  an 
average  of  42  days  per  case  a  year,  were  spent  in  the  hospital.     Not  a  single  day  \yas 
spent  in  the  hospital  by  the  samp  6  cases  after  entering  the  class  for  cardiacs.     A  saving 
of  $439.25  was   thus  effected.      Moreover,   the  earning  capacity  of  35   patients   was   in- 
creased from   $12,477   before  attending  the  class  to  $20,347.50   after  attending,  an   in- 
crease of  71  per  cent. 


TRAINING    OF    TEACHERS   FOR    OCCUPATIONAL    THERAPY.  41 

In  arthritis  the  situation  is  somewhat  the  same  as  in  heart  disease. 

Much  of  this  class  will  naturally  be  cared  for  along  with  heart  disease,  and 
heart  disease  is  going  to  be  covered  in  more  comprehensive  ways  in  the  neap 
future.1 

Arthritis,  paralysis,  and  deformities  following  nerve  injuries, 
and  selected  cases  of  tabes  dorsalis  are  benefited  if  muscles  and  joints, 
are  not  allowed  to  stiffen  and  become  inactive.  Patients  suffering 
from  kidney  trouble  are  liable  to  extreme  fatigue  and  lassitude. 
Their  occupation  must  be  light,  and  they  must  not  be  exposed  to 
cold  or  uneven  temperature. 

In  all  cases  of  general  debility,  protracted  surgical  dressing  cases, 
and  serious  internal  diseases,  convalescence  is  an  important  feature 
of  recovery.  As  Dr.  Brush  has  said  of  convalescent  institutions,  they 
adopt  the  most  effective  restorative  agency  known  "to  the  half- 
sick,  the  handicapped  and  subnormal,  the  failing,  the  depressed. 
Sleep,  exercise,  rest,  feeding,  amusements,  diversional  and 
hardening  occupations,  companionships,  care  of  minor  ills,  mental 
and  moral  slants,  home  betterments  at  the  same  time,  and  future  enx 
ployment  are  all  studied  and  adjusted  to  the  individual  *  *  * 
and  the  results  are  inevitable  and  inspiringly  good." 

Dr.  Brush  describes  his  occupational  treatment  at  the  Burke  Foun-: 
dations,  White  Plains,  N.  Y.  He  says : 

One  soon  learns  that  convalescence  at  best  is  fully  half  mental.  Our  occupa- 
tion is  considered  not  chiefly  diversional  but  remedial,  reconstructive,  curative, 
convalescent,  normalizing.  It  is  not  a  side  issue;  it  costs;  it  is  our  best  medi- 
cine. It  is  prescribed,  in  writing,  for  more  than  one-fourth  cardiacs,  hyper- 
thyroids,  choreics,  all  the  border  mental  and  nerve  folks,  the  inherently  restless, 
all  long  stayers,  the  temperamentally  difficult,  the  quitters,  the  pampered,  the 
disheartened. 

Of  the  result  of  the  work  cure  he  has  said : 

We  have  records  of  these  people  back  at  normal  living.  We  are  knowing 
that  they  were  not  lazy — only  mislead,  mismanaged,  misenviroued.  Now  come 
the  newer  long-term  and  more  testing  phases,  giving  (ever  wTith  a  small  per- 
centage of  failures)  end-products,  which  may  be  indicated  as  follows:  Cardiacs 
who  have  been  much  in  hospitals  and  dependence  strengthened  to  maintain 
steady  occupation ;  *  *  *  nearly  nervous  and  mental  borderliners  of  many 
kinds,  turned  back  by  occupational  and  mental  therapy  principally  to  fair  liva- 
bility  and  content,  *  *  *  rheumatics  in  limited  selection,  given  long  terms, 
particularly  for  their  hearts'  sake,  and  at  last  sufficiently  toughened  for  com- 
petition by  graduated  play  and  work,  *  *  *  various  subnormal  youths  set 
forward  with  weight,  blood,  nerve,  posture  and  character,  and  educational  addi- 
tions that  are  fairly  permanent;  protracted  surgical  dressing  cases  in  large 
numbers  carried  to  earlier  and  solider  healing  plus  hardening  for  work,  hyper- 
thyroidism  afforded  long  rest  plus  nerve  and  heart  training  with  notably  worthy 
results  *  *  *  these  are  some  of  the  better  and  harder  things  now  being 
done  in  convalescent  institutions. 

ORTHOPEDIC   SURGERY. 

The  following  classification  of  orthopedic  cases  corresponds  to  that  which  haa 
been  decided  upon  by  the  British  Government  and  is  the  outlined  classification 
of  the  Surgeon  General  of  the  United  States  Army : 

(a)  Derangements  and  disabilities  of  joints,  simple  and  grave,  including 
anchylosis. 

(ft)  Deformities  and  disabilities  of  feet,  such  as  hallux  valgus,  hallux  rigidua, 
hammer  toes,  metatarsalgia,  painful  heels,  flat  and  claw  feet! 

1  Dr.  Frederic  Brush.  The  Convalescent  Field — Its  New  and  Changing  Border  Lines. 
Modern  Hospital,  June,  1916. 


42  TRAINING    OP    TEACHERS    FOR    OCCUPATIONAL    THERAPY. 

(o   M.iluuited  and  miimited  fractures. 

(</)   Injuries  to  ligaments,  muscles,  and  tendons. 

(e)  Cases  requiring  tendon  transplantation  or  other  treatment  for  irreparable 
destruction  of  the  nerves. 

(f)  Nerve  injuries  complicated  by  fractures  or  stiffness  of  joint. 
(#)   Cases  requiring  surgical  appliances. 

(h)   Cases  requiring  treatment  of  stump  and  fitting  of  artificial  limbs. 

Occupational  therapy  has  a  distinct  and  definite  purpose  in  the 
functional  adaptation  and  reeducation  of  many  of  these  orthopedic 
cases. 

The  term  "  orthopedic  surgery  "  is  used  in  the  comprehensive  sense 
in  which  it  is  employed  by  Col.  Sir  Robert  Jones,  0.  B. : 

The  modern  conception  of  orthopedic  surgery  *  *  *  may  be  broadly  de- 
fined to  be  the  treatment  by  manipulation,  by  operation,  and  by  reeducation 
of  disabilities  of  the  locoruotor  system  whether  arising  from  disease  or  injury. 

For  lesions  in  and  about  the  joints,  the  workshops  are  a  valuable 
part  of  the  hospital  equipment. 

In  all  cases,  whether  operation  is  necessary  or  not,  the  treatment  is  a  lengthy 
one,  since  exercises  are  necessary  for  many  months  before  the  joints  can  be 
made  to  function  properly.  In  such  instances,  workshops  are  a  valuable  ad- 
junct to  the  hospital  equipment  since  they  furnish  not  merely  vocational  train- 
ing, but  the  most  effective  means  of  exercising  the  injured  joint.1 

Static  deformities  cover  a  long  period  of  treatment  in  which  the 
patient  is  far  from  helpless  and  in  which  a  better  physical  condi- 
tion is  maintained  if  he  has  proper  exercises. 

Bone  injuries  necessarily  require  a  long-  period  of  convalescence. 
The  modern  treatment  of  many  bone  injuries,  as  differentiated  from 
the  old  method,  is  that  the  parts  when  properly  supported  are  not 
harmed  by  use,  and  that  the  danger  of  stiffening  and  functional  im- 
pairment "is  lessened  by  the  activity  prescribed  in  the  hospital  work- 
shop. 

In  the  postoperative  treatment  of  tendon  injuries,  it  is  necessary 
to  have  exact  scientific  knowledge  as  to  when  the  tendon  has  healed 
so  that  it  may  be  safely  exercised.  When  the  physician  determines 
that  point,  exercise  must  begin  and  regulated  active  movements  in 
the  hospital  workshop  are  then  invaluable. 

Nerve  injuries  require  a  long  period  of  treatment  in  which  the 
muscles  must  be  kept  in  the  best  possible  condition.  The  use  of  ap- 
paratus and  extreme  watchfulness  in  occupation  often  prevent  the 
muscle  structures  from  becoming  either  stretched  or  contracted. 

The  cases  of  amputations  require  a  period  sometimes  as  long  as 
several  months  before  the  prosthetic  appliance  may  be  finally  ad- 
justed and  fitted  to  the  stump.  During  this  period  occupational 
therapy,  with  its  properly  directed  exercises,  must  develop  whatever 
latent  power  there  is  in  the  stump. 

Characteristic  of  all  these  groups  of  patients  is  their  chronic. nature  *  *  * 
in  almost  every  instance,  a  lengthy  postoperative  treatment.  The  crippling 
nature  of  the  injury,  its  long  duration,  the  apparent  inability  to  earn  a  liveli- 
hood, have  all  depressed  the  patient  to  a  marked  degree.1 

OCCUPATIONAL  THERAPY  AND  THE  WAR  INVALID. 

The  disability  of  the  war  invalids  cover  a  wide  range,  including 
all  those  diseases,  chronic  and  accute  infections,  mental  and  nervous 


1  Dr.  Leo  M;iyor.     American  Journal  of  Care  for  Cripples,  Vol.  V.  No.  1. 


TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL  THERAPY.  43 

disorders,  accidents,  and  injuries  which  are  frequent  in  large  gen- 
eral hospitals.  In  addition  to  these  there  are  the  particular  disa- 
bilities of  the  war,  shrapnel  wounds,  shell  shock,  gas  poisoning,  the 
effect  of  explosives,  and  the  extreme  prostration  of  trench  strain. 
A  close  analysis  of  the  three  largest  groups  of  disabilities — first,  the 
war  psychoses  and  neuroses;  second,  internal  diseases  and  injuries; 
and,  third,  cases  requiring  orthopedic  surgery — will  make  clear  the 
reason  why  occupational  therapy  has  been  found  to  be  more  invalu- 
able in  the  treatment  of  war  invalids  than  in  civilian  patients. 

Ten  per  cent  of  4,000  eases  surveyed  in  Canada  were  found  to  be 
nervous  and  mental  cases.  An  analysis  of  these  showed  that  60  per 
cent  were  nervous,  25  per  cent  mental,  and  15  per  cent  epileptics.1 
Fifteen  per  cent  of  the  discharged  men  from  the  British  Army  are 
unrecovered  cases  of  mental  diseases  and  war  neuroses.2  Dr.  Thomas 
W.  Salmon,  medical  director  of  the  National  Committee  for  Mental 
Hygiene,  states  that  on  the  basis  of  1,000,000  men  overseas  the 
country  may  expect  250  insane  soldiers  per  month.2 

The  popular  idea  that  every  disabled  man  is  a  cripple  is  disproved 
by  the  figures  of  the  interallied  conference  held  in  JParis  May  8-12, 
1917.  These  figures  show  only  167  cases  of  amputation  in  every 
1,000  disabilities.  Consequently  833  cases  in  every  1,000  are  injuries 
of  other  kinds.  The  men  are  classified  according  to  their  most  se- 
rious disability,  but  in  14  per  cent  or  15  per  cent  of  all  cases  there  are 
two  or  three  or  even  four  injuries.  Blindness  is  given  as  low  as  less 
than  1  per  cent  of  the  disabilities,3  and  French  figures  give  the  per- 
centage of  blindness  to  be  0.05  per  cent  of  all  the  soldiers  engaged  in 
battle.4 

MENTAL  AND   NERVOUS   DISORDERS. 

The  number  of  mental  and  nervous  cases  is  misleading,  inasmuch 
as  only  the  acute  forms  are  diagnosed  as  war  psychoses  and  neuroses. 
Except  in  degree,  they  are  not  unlike  many  mild  forms  which  exist 
in  connection  with  many  other  disabilities. 

The  increased  number  of  commitments  to  insane  hospitals  since 
the  war  is  evidence  of  the  unbalancing  effect  of  war  upon  the  civil 
population.  It  may  be  guessed  to  what  greater  extent  the  actual 
participants  in  the  war  are  subjected  to  similar  disorders. 

The  surgeon,  Desault,  noted  that  during  the  French  Revolution 
diseases  of  the  heart  and  enlargement  of  the  aorta  were  increased. 
Prof.  Amar  says  in  this  connection  that  the  number  of  old  people 
who  died  during  the  course  of  the  present  war  has  been  greatly 
increased.5 

In  speaking  of  the  psychic  condition  resulting  from  the  present 
war,  Prof.  Amar  further  states : 

It  has  disturbed  the  higher  nervous  centers  and  has  often  prevented  the 
proper  functioning  of  the  brain.  It  has  inclined  thousands  of  wounded  to 

1  Military   Hospitals  Commission. 

*  Psychiatric  Bulletin  of  the  New  York  Hospitals,  July,  1917. 

3  Conference  Interaliee,  Rapports. 

4  How   France  Returns   Soldiers  to  Civilian   Life,   by   J.   L.  Tbdd. 

E  The  violence  of  the  emotion,  Prof.  Amar  explains,  excites  the  bulb  of  the  aorta  and 
results  in  palpitation  or  syncope.  The  pneumogastric  or  vagus  nerve  starts  in  the 
medulla  oblongata  and  its  branches  extend  to  the  bead,  neck,  thorax,  and  abdomen.  Its 
activity  impedes  and  tends  to  inhibit  the  heart,  and  this  affects  all  parts  of  the  body  by 
a  change  in  the  amount  of  the  blood  which  circulates  through  them.  The  brain  is 
therefore  affected  and  the  cardiac  phenomena  are  complicated  by  cerebral  anemia  and 
physical  depression. 


44  TRAINING    OF    TEAGHEES   FOE   OCCUPATIONAL   THERAPY. 

mental  disorders,  phobias,  hallucinations,  and  different  and  rather  obscure 
psychoses.  Organic  troubles  and  decay  of  nerve  centers  have  become  more 
frequent  as  a  result  of  this  terrible  war  than  ever  in  the  knowledge  of  man.1 

It  has  long  been  recognized  that  a  serious  consequence  of  any 
long  convalescence  may  be  the  mental  depression  and  lassitude  which 
renders  the  victim  unable  to  adjust  himself  to  normal  life.  This 
.state  of  mind  is  further  intensified  when  it  exists  in  connection  with 
a  real  physical  handicap  and  when,  in  addition,  the  patient  has 
been  subjected  to  great  nervous  tension.  The  strain  of  trench  war- 
fare, the  idle  hours  of  waiting,  the  submission  to  discipline,  and 
lack  of  individual  initiative  render  the  war  invalid  particularly 
susceptible  to  this  mental  condition. 

Dr.  Bourillion,  head  of  St.  Maurice,  one  of  the  most  important 
French  hospitals,  has  said : 

Our  young  wounded  soldiers,  weakened  by  violent  and  prolonged  sufferings, 
dangerous  operations,  and  nervous  shock  have  had  their  equilibrium  rudely 
shaken  and  disturbed.  Such  shocks  to  their  physical  organization  are  bound 
to  react  on  their  mental  and  moral  condition.  *  *  *  Add  to  this  their 
isolation,  their  natural  preoccupation  in  their  own  fate  and  that  of  those  dear 
to  them,  and  it  will  explain  the  kind  of  inertia,  the  decay  of  will  power,  and 
the  apparent  indifference  to  the  future  which  gives  the  impression  that  the 
majority  of  them  are  incapable  of  ever  again  realizing  the  joy  of  work. 

No  medical  treatment  alone  can  solve  the  mental  phase  of  the 
problem.  It  is  peculiarly  the  field  of  occupational  therapy. 

Dr.  F.  H.  Sexton,2  of  Halifax,  tells  of  the  incompleteness  of 
medical  treatment  alone.  In  speaking  of  the  soldiers  in  convalescent 
homes  in  Canada  he  has  said: 

We  found  that  these  men  instead  of  becoming  better  under  the  medical 
treatment,  were  absolutely  deteriorating  mentally  and  otherwise  and  were  ill 
danger  of  becoming  so  hospitalized  that  they  would  never  go  back  to  their 
civilian  work  with  any  vim. 

Therefore,  we  decided  that  they  must  have  some  kind  of  occupation  and 
that  they  must  have  some  kind  of  work.  I  do  not  suppose  that  there  is  any- 
body that  does  not  know  that  work  is  the  greatest  curative  in  the  world.  So 
we  began  right  away  as  soon  as  the  military  hospitals  commission  had  an 
accurate  idea  of  the  situation  and  supplied  some  kind  of  occupation  for  every 
one  of  the  returned  soldiers.  This  was  extended  until  it  included  even  active 
cases  in  the  hospital.  The  man  who  was  flat  on  his  back  and  could  raise  his 
hand  was  given  something  to  do,  if  he  desired  to  do  something  to  while  away 
the  time  and  the  medical  officer  had  said  he  could  take  up  some  light  work. 
*  *  *  It  was  found  to  be  so  good  for  the  men  that  after  an  experience  of 
six  months  it  was  made  compulsory,  and  to-day  unless  a  man  is  excused  by 
his  medical  officer  he  has  to  enter  the  vocational  classes  as  part  of  his  daily 
routine. 

The  curative  workshops  in  the  reconstruction  hospitals  help  the 
majority  of  the  mild  mental  and  nervous  cases  to  recovery,  but  those 
severe  affections  definitely  classed  as  war  psychoses  and  neuroses 
must  undergo  a  long  period  of  convalescence  in  which  occupational 
therapy  is  an  important  feature  of  the  treatment. 

It  is  highly  desirable  that  these  men,  to  whom  one  is  all  the  more  indebted 
because  they  have  suffered  greatly  and  must  suffer  mentally  and  physically  in 
the  future,  should  imagine  for  one  moment  that  they  are  herded  into  an  asylum 
as  incurable  because  they  would  be  burdensome  elsewhere.  The  whole 

future  of  these  patients  depends  on  the  care  they  receive.  Given  constant  care 
and  a  well-thought-out  system  of  functional  reeducation,  astonishing  improve- 
ment may  be  anticipated  in  some  cases.3 

1  Translated  from  Organisation  Thysiologique  du  Travail,  by  Jules  Amar. 

2  Address  givou  in  Rochester,  X.   Y..   Nov.   15,  1917. 

2  Resolution  passed  May  11,  1917,  interallied  conference,  Paris, 


TRAINING   OF    TEACHERS   FOR    OCCUPATIONAL   THERAPY.  45 

Dr.  Salmon  has  said : 

Few  more  hopeful  cases  exist  in  the  medical  services  of  the  countries  at  war 
than  those  suffering  from  the  war  neuroses  grouped  under  the  term  "  shell 
shock  "  when  treated  in  special  hospitals  by  physicians  and  nurses  familiar  with 
the  nature  of  functional  nervous  diseases  and  with  their  management.  On  the 
other  hand,  the  general  military  hospitals  and  convalescent  camps  presented 
no  more  pathetic  picture  than  the  mismanaged  nervous  and  mental  cases  which 
crowded  their  wards  before  such  special  hospitals  were  established.  Exposed  to 
misdirected  harshness  or  to  equally  misdirected  sympathy,  dealt  with  at  one 
time  as  malingerers  and  at  another  as  sufferers  from  incurable  organic  nervous 
disease,  passed  on  from  one  hospital  to  another,  and  finally  discharged  with 
pensions  which  can  not  subsequently  be  diminished,  their  treatment  has  been  a 
sad  chapter  in  military  medicine.1  As  one  writer  has  said,  "  They  enter  the 
hospitals  as  *  shell-shock '  cases  and  come  out  as  nervous  wrecks."  To  their 
initial  neurological  disability  (of  a  distinctively  recoverable  nature)  are  added 
such  secondary  effects  as  unfavorable  habit  reactions,  sterotypy  and  fixation 
of  symptoms,  the  self-pity  of  the  confirmed  hysteric,  the  morbid  timidity  and 
anxiety  of  the  neurasthenic,  and  the  despair  of  the  hypochondriac.  In  such 
hospitals  and  convalescent  homes  inactivity  and  aimless  lounging  weaken  the 
will,  and  the  attitude  of  permanent  invalidism  quickly  replaces  that  of  recov- 
ery. *  When  the  patients  and  staff  have  been  suitably  housed,  atten- 
tion should  be  directed  to  the  highly  important  features  of  shops,  industrial 
equipment,  gymnasium,  and  gardens.  *  *  * 

Second  in  importance  only  to  the  general  psychological  control  of  the  situa- 
tion in  functional  nervous  diseases  is  the  restoration  of  .the  lost  or  impaired 
functions  by  reeducation.  None  of  the  methods  available  for  reeducation  are 
so  valuable  in  the  war  neuroses  as  those  in  which  a  useful  occupation  is  em- 
ployed as  the  means  for  training.  Reeducation  should  commence  as  soon  as 
the  patient  is  received.  Thought,  will,  feeling,  and  function  have  all  to  be 
restored,  and  work  toward  all  these  ends  should  be  undertaken  simultaneously. 

There  is  no  class  of  patfents  for  whom  occupational  therapy  is 
more  necessary  and  for  whom  the  most  skilled  instructors  should  be 
chosen  than  this  one. 

Work 2  should  be  given  only  as  a  medical  prescription ;  it  should  be  prescribed 
only  after  careful  mental  and  physical  examination  and  with  as  much  thought 
on  the  part  of  the  physician  as  he  would  use  in  determining  whether  a  given 
patient  needs  a  vogotonic  or  a  sympathicotonic  drug. 

"  It  seems  that  tools  and  machines  were  first  introduced  merely  with  the  idea 
of  giving  the  patients  something  to  do.  The  hours  and  conditions  of  use  were 
prescribed  by  the  medical  superintendent  according  to  the  condition  of  the 
patient.  *  You  can  not  conceive  the  difference  in  the  condition  of  the  men,'  said 
one  of  the  medical  superintendents  in  the  course  of  his  evidence.  '  It  is  simply 
marvelous  how  much  happier  and  more  contented  they  become  with  something 
to  do.  They  eat  better,  put  on  weight,  and  submit  to  regulations  more  willingly, 
thus  hastening  their  ultimate  discharge.  I  have  not  had  one-tenth  the  trouble 
with  discipline  since  vocational  training  was  installed.' " 

I! VJTKKNAL  DISEASES,    INJURIES,    AND   POST-SURGICAL   TREATMENT    (NOT    ORTHOPEDIC). 

The  most  frequent  disabilities  of  returned  men  in  the  Montreal 
office  are  rheumatism,  heart  trouble,  and  tuberculosis.  Occupational 
therapy  has  been  found  to  have  a  definite  physiological  function  in 
the  convalescence  of  a  large  group  of  internal  diseases  and  injuries. 
Prof.  Amar  has  stated  that  deficiency  of  cardiac  activity  is  particu- 
larly to  be  watched  for  among  the  older  wounded  soldiers. 

1  When  the  sufferers  from  war  neuroses  have  been  allowed  to   return  to  their  home 
communities,    a    serious   social    and   economic    problem    has    arisen,    "  so   serious    that   a 
special  sanitarium — the  Home  of  Recovery — the  first  of  several  to  be  provided,  has  been 
established  in  London  and  subsidized  by  the  war  office  for  the  treatment  of  such  cases 
among  pensioners." 

2  Dr.  A.  J.  Ruggles.  in  Modern  Hospital,  Juno,   1917. 

3  Recalled  to  Life,  No.  2. 


46  TRAINING  OF   TEACHKRS  FOR  OCCUPATIONAL  THERAPY. 

It  is  necessary  to  know  how  to  discover  the  cardiovascular  and  pulmonary 
affections  in  order  to  establish  with  surety  the  physical  fitness  and  the  degree 
of  endurance  of  the  wounded.1 

The  disabled  soldiers  are  particularly  liable  to  fatigue,  and  by 
graduated  exercises  their  resistance  may  be  increased  and  the  degree 
of  exercise  that  will  not  affect  their  organic  difficulty  be  determined. 

Occupational  therapy  is  especially  valuable  to  cheer  the  convalesc- 
ing soldier  and  balance  his  nervous  system,  since  his  physical  condi- 
tion is  not  infrequently  aggravated  as  the  result  of  nerve  strain.2 
After  a  prostrating  experience  he  is  subjected  to  the  enervation  of 
institutional  life,  and  unless  he  is  a  very  unusual  patient  he  antici- 
pates a  "  soft  job,"  if  indeed  any  job  at  all,  little  realizing  that  there 
are  applicants  far  in  excess  of  such  positions,  while  industry  is 
severely  handicapped  by  a  lack  of  skilled  labor.  Occupational 
therapy  must  help  these  patients  to  recover  in  every  way  by  creating 
in  them  the  desire  to  make  the  best  of  their  conditions  and  by  teach- 
ing them  new  trades  or  greater  expertness  in  old  ones  so  that  their 
remaining  years  may  be  productive.  These  physiological  effects 
of  vocational  exercises  are  'now  used  with  profit  in  the  Austro-Ger- 
man  hospitals  under  the  name  "Arbeits-therapy." 

ORTHOPEDIC    SURGERY. 

There  is  no  branch  of  medicine  which  has  made  more  rapid  strides 
of  progress  in  the  last  four  years  than  the  science  of  orthopedic 
surgery.  A  new  value  and  emphasis  have  been  placed  upon  regulated 
exercise  and  occupational  therapy.  Occupation  accomplishes  more 
for  this  group  than  the  somewhat  negative  function  of  passing  time. 
It  provides  regulated  activity  and  exercise  of  prescribed  muscles 
which  is  necessary  in  functional  readaptation  or  the  reeducation  of 
any  injured  part. 

Experience  in  foreign  hospitals  has  proved  that  functional  readap- 
tation is  greatly  facilitated  in  the  hospital  workshop.  For  instance, 
in  cases  of  amputation — 

Reeducation  of  the  stumps  produces  an  improvement  through  a  physiologi- 
cal state,  reaclapts  the  patients,  and  combats  the  menace  of  nervous  degenera- 
tion. It  then  permits  the  prosthetic  apparatus  to  operate  perfectly  and  with  a 
better  use  of  touch  and  muscle.1 

The  latent  power  in  the  stump  is  developed  and  trophic  complica- 
tions avoided  by  exercise.  The  extent  of  the  injury  and  the  result 
to  be  achieved  call  for  different  occupations  and  exercises.  Walk- 
ing, for  instance,  or  the  effort  required  in  moving  the  shoulders  or 
elbows  requires  force,  a  combination  of  muscular  effort,  and  a  series 
of  small  movements,  whereas  writing  merely  exercises  the  fingers. 

An  important  war  contribution  made  to  orthopedics  is  properly 
directed  exercise  of  a  practical  type  in  the  hospital  workshops. 

Nothing  has  been  more  remarkable  than  the  overthrow  of  the  old-fashioned, 
purposeless  orthopedic  exercises  for  the  cure  of  muscle  weakness,  stiff  joints, 

1  Translated  from  Organisation  Physiologique  du  Travail,  by  Jules  Amar. 

2  The  attitude  of  the  man  is  suggested  in  the  following  extract  from  Good  News   for 
the  Disabled  Soldier  and  Sailor,  a  pamphlet  for  the  information  of  discharged  men  and 
printed  in  the  first  number  of  Recalled  to  Life  : 

"  How  different  things  are  now  that  you  are  back  in  '  Blighty.'  In  the  stress  of  life 
during  your  military  training,  and  on  active  service,  time  passed  too  quickly,  and  you 
could  not  think  of  anything  but  just  '  carrying-on.'  But  now,  lying  in  bed  or  in  con- 
valescence, time  hangs  heavily  on  your  hands  and  you  begin  to  think,  think,,  think.  And 
doubtless  as  you  feel  yourself  a  shattered  man,  either  handicapped  by  the  loss  of  a  limb 
or  otherwise  disabled,  you  carry  your  thoughts  back  over  the  past  two  years." 


TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL   THERAPY.  47 

etc.  Under  the  influence  of  the  teaching  of  Col.  Sir  Robert  Jones,  C.  B.,  useful 
manual  work  has  largely  supplanted  the  older  system  of  mechanotherapy.  The 
bench,  the  workshop,  and  the  gymnasium  provide  for  the  active  movements  of 
joints  and  of  limbs,  in  contradistinction  to  the,  for  the  most  part,  passive 
movements  of  the  appliances  hitherto  in  use,  while  at  the  same  time  the  patient, 
being  provided  with  a  useful  occupation,  lends  himself  more  readily  to  the  treat- 
ment prescribed  for  him  and  becomes  interested  in  it.  The  chief  point  to  re- 
member is  that  each  piece  of  work  performed  is  a  prescription  ordered  by  the 
surgeon  for  a  specific  joint  or  muscle  disability. 

For  instance,  a  man  suffering  from  dropped  foot  instead  of  having  to  pedal  a 
dummy  bicycle  now  works  a  fret  saw,  foot  lathes,  or,  in  the  case  of  certain 
injuries  to  the  arm  and  hand,  the  man  is  put  to  work  with  saw,  plane,  or  other 
tools  and  thus  accomplishes  himself,  by  means  of  natural  movements,  results 
which  previously  have  only  been  obtained  by  means  of  massage,  physical  exer- 
cise, etc.  Methods  such  as  these  are  very  successful,  as  it  will  be  agreed  that 
it  is  much  easier  to  get  a  man  better  by  a  natural  process  than  by  an  artificial 
one.1 

Col  Jones  himself  says,  as  a  result  of  his  experience  in  English 
hospitals : 

As  soon  as  the  patient  is  fit  to  get  about  he  should  have  some  occupation 
both  for  his  mental,  moral,  and  physical  welfare.  Here  the  curative  workshop 
is  an  invaluable  aid  to  his  gymnastic  treatment.  *  *  * 

Excellent  and  useful  as  systematic  gymnastic  training  is  for  developing 
movement,  the  training  in  coordination  in  doing  purposeful  work  is  what 
really  brings  brain  and  muscle  once  more  into  proper  accord,  while  regular 
daily  work  reestablishes  in  the  patient  habits  of  responsibility  and  self- 
respect.  *  *  *  For  example,  a  man  with  stiff  fingers  barely  able  to  grasp 
even  fairly  large  objects,  is  soon  utterly  wearied  if  set  to  grasp  spring  dumb- 
bells or  any  other  such  apparatus,  but  will  cheerfully  spend  the  morning  grasp- 
ing a  big  duster  and  clearing  windows.  *  *  *  Later,  if  he  is  a  carpenter 
or  other  skilled  tradesman,  he  is  promoted  to  the  use  of  tools  he  understands, 
and  so  the  disabled  hand  is  reeducated  partly  by  set  gymnastic  exercises  and 
largely  by  work. 

Driving  a  plane  in  the  carpenter's  work  can  be  employed  for  exercising  mus- 
cles and  joints  in  both  arms  and  legs.  *  *  *  His  brain  is  interested  in  what 
his  hands  are  doing  and  not  wearied  by  the  curative  action  which  the  treadle 
movement  brings  about 

The  experience  of  France,  Belgium,  Germany,  Austria,  Canada, 
and  England  has  proved  the  greater  value  of  active  movement  ini- 
tiated by  the  patient  himself  over  any  system  of  Zander  movements 
or  mechanotherapeutics,  however  elaborate. 

Of  the  orthopedic  treatment  in  Canada  Mr.  Kidner  and  Mr.  Todd 
have  said : 

Institutions  carrying  out  functional  reeducation  employ  treatment  by  active 
and  passive  mechanotherapy,  by  galvanic,  static,  faraclic  and  high-tension 
electric  currents,  by  vibration,  by  bathing  and  blasts  of  hot  air,  by  baths  of 
many  kinds,  by  colored  lights,  by  massage,  gymnastics,  and  exercises  of  various 
sorts.  Although  such  a  variety  o'f  methods  exist,  opinion  is  universal  in  insist- 
ing that  work,  properly  selected  and  graduated,  has  the  highest  therapeutic 
and  psychic  value  and  constitutes  the  best  possible  means  of  reaccustorning 
muscles  and  the  mind  to  action.  Whenever  possible  the  work  given — occu- 
pational therapy — constitutes  an  introduction  to  the  vocational  training,  prop- 
erly speaking,  which  will  be  given  later  should  it  be  necessary  to  do  so.  Passive 
mechanotherapy  is  little  used.  Experience  has  completely  demonstrated  the 
greater  value  of  active  movement  initiated  by  the  patient  himself. 

A  distinct  accomplishment  of  occupational  therapy  and  one  which 
is  not  often  realized  is  the  conserving  of  the  patient's  energy.  This 
is  a  matter  of  no  small  importance  to  the  handicapped  who  labor 
under  physical  impairment  and  are  subject  to  extreme  fatigue.  The 

1  A  memorandum  prepared  by  Sir  Alfred  Keogh,  G.  C.-  B.,  director  general,  army  med- 
ical service  for  the  Anglo-Belgian  committee. 


48  TRAINING    OF    TEACHERS  FOR  OCCUPATIONAL   THERAPY. 

patient  is  taught  to  eliminate  wasteful  effort  and  is  shown  how  to 
achieve  the  best  results  with  the  least  expenditure  of  energy. 

THE   NEED   FOR   IMMEDIATE   OCCUPATION. 

The  mental  condition  of  the  disabled  soldier  or  sailor  is  such  that 
if  a  delay  occurs  before  he  is  given  an  occupation  he  frequently  be- 
comes institutionalized  and  unable  to  adapt  himself  to  the  thought 
of  productive  work.  Unless  the  large  margin  of  waste  time  in  the 
medical  treatment  is  occupied  in  some  way  from  the  very  first,  the 
patients  will  become  "  incurable  loafers  "  and  degenerate  after  a  long 
convalescence  into  that  chronic  invalidism  which  is  mental  rather 
than  physical. 

The  effect  on  the  mental  outlook  of  the  wounded  man  is  equally  important. 
A  soldier  is  either  fit  for  duty  or  he  is  in  a  hospital.  After  lying  in  bed  weeks 
or  months  while  septic  wounds  have  been  slowly  healing,  he  has  often  lost 
much  of  his  spirit  and  initiative.  If  he  is  in  a  hospital  where  there  is  nothing 
definite  for  him  to  do,  he  is  apt  during  his  convalescence  to  learn  the  habit  of 
getting  through  the  day  without  doing  anything  more  energetic  than  smoking, 
playing  cards,  and  listening  to  a  concert,  or,  if  out,  going  to  a  cinematograph 
show.  When,  however,  the  patient  is  in  an  atmosphere  of  work  he  soon  recovers 
some  hold  on  himself  and  wishes  to  do  something,  especially  when  the  satis- 
factory performance  of  his  work  earns  some  small  extra  privileges.  As  his 
power  to  work  increases  he  ceases  to  think  so  much  of  himself  as  a  maimed 
man,  but  begins  to  think  of  what  he  will  be  able  to  do  in  the  future.1 

It  is  of  the  utmost  importance  that  occupation  begin  as  soon  as  the 
patient  is  considered  fit  by  the  medical  authorities.  Experience  has 
proved  that  the  ease  with  which  men  become  adjusted  and  employ- 
able is  in  direct  ratio  to  the  promptness  with  which  reeducation  was 
begun.  Mr.  L.  G.  Brock  has  said : 

The  question  is  desperately  urgent.  Habits  of  idleness  are  not  easily  shaken 
off,  and  if  once  these  men  are  siikwd  to  sink  into  despondency  and  apathy  they 
will  soon  degenerate  into  chronic  uuemployables.  Delay  means  wasted  lives. 

French  experience  shows  that  only  5  per  cent  of  those  wrho  com- 
mence training  in  hospitals  failed  to  continue,  whereas  80  per  cent 
took  no  training  at  all  if  training  was  deferred.2 

The  danger  of  institutionalizing  can  only  be  forestalled  by  the 
prompt  action  of  enlightening  the  minds  and  sustaining  the  weakened 
wills  of  the  long  convalescent  patients. 

"  Every  delay,"  says  Dr.  Bourillion,  "  in  carrying  out  this  sugges- 
tion increases  the  chances  of  seeing  them  overcome  by  the  evils  of 
indolence." 

THE  PRESENT  FIELD  OF  OCCUPATIONAL  THERAPY,  AND  ITS 
POSSIBILITIES  OF  DEVELOPMENT. 

Occupational  therapy 3  is  neither  a  new  movement  nor  one  which 
has  suddenly  come  into  prominence  through  a  spectacular  publicity 
campaign.  It  is,  rather,  a  movement  which  has  gradually  developed 
by  justifying  itself  over  a  long  period  of  years.  It  was  'initiated  by 
the  doctors  in  insane  hospitals  who  first  dared  the  experiment  of 
putting  their  patients  to  work ;  and  by  those  other  doctors  who  were 
groping  after  something  which  might  give  to  their  neurasthenic 

1  Sir  Robert  Jones,  C.  B.,  in  Recalled  to  Life,  No.  1. 

2  Bulletin  No.   1,   Annee  1916,   office  National  des  Mutiles  et  reformes   cle  la   guerre. 
"The  history  of  occupational  therapy,''  by  William  Hush  Dunlon,  jr.,  Modern  Hospital, 

June,  1917,  and  "  Occupational  therapy,  a  manual  for  nurses,"  by  the  same  author. 


OF  TEACHERS  FOE  OCCUPATIONAL  THERAPY.  49 

patients  a  health}7  interest  and  a  new  grip  on  life.  The  healing  value 
of  occupation  is  so  well  established  that  occupational  therapy  is  no 
longer  confined  to  the  insane  or  neurasthenic  but  has  been  found 
equally  beneficent  in  tuberculosis,  in  long  orthopedic  treatments,  and 
in  extensive  convalescences  in  a  general  hospital. 

The  crafts,  with  their  variety  and  scope,  are  well  adapted  to  the 
needs  of  the  occupational  therapeutist.  A  craft  is  quickly  learned, 
the  equipment  is  simple  and  inexpensive,  and  varying  degrees  or 
mental  or  physical  exertion  are  possible.  Art  and  craft  are  closely 
interwoven,  and  art  especially  affords  a  channel  for  self-expression 
which  is  in  many;  cases  the  keynote  of  the  success  of  occupational 
therapy.  There  is  in  the  crafts  just  that  poise,  opportunity  for 
creation,  and  interest  in  execution  which  on  a  first  glance  seems  to 
counteract  strain,  overspecialization,  and  the  monotony  of  the  fac- 
tory system.  It  is  not  strange  that  those  doctors  who  see  the  disas- 
trous by-products  of  modern  industrialism  should  favor  the  crafts 
and  simple  hand  industries  as  occupations  well  fitted  for  the  hospital 
workshops.  Occupational  therapy  has  justified  itself  purely  as  a 
medical  agent  and  has  proved  beyond  a  doubt  the  value  of  (Occupa- 
tion as  a  therapeutic  measure.  The  crafts  have  met  all  the  thera- 
peutic qualifications  of  occupations  and  the  tendency  has  therefore 
been  to  consider  them  the  logical  channels  of  expression  and  to  re- 
quire a  knowledge  of  art  and  craft  in  the  training  for  teachers. 

Occupational  therapy  has  up  to  the  present  made  no  pretense  to 
provide  vocational  training.  Yet  the  instruction  received  during 
convalescence  has  been  of  direct  economic  value  to  a  few  patients 
who,  after  a  hospital  experience,  have  been  better  equipped  for  earn- 
ing their  living.  The  children's  teacher  in  connection  with  the  City 
Hospital  of  Cincinnati  gave  instruction  to  several  convelescing  young 
men,  with  the  result  that  they  secured  better  positions  after  leaving 
the  hospital  than  they  had  held  before,  and  a  few  even  passed  civil- 
service  examinations.  The  reason  that  these  cases  are  as  rare  as  they 
are  may  be  partly  due  to  the  fact  that  the  institutions  which  nave 
adopted  occupational  therapy  are  not,  as  a  rule,  those  to  which  the 
working  man  goes,  unless  he  be  tubercular  or  a  chronic  invalid. 
With  the  possible  exception  of  Massachusetts  General  Hospital,  the 
City  Hospital  of  Cincinnati,  the  Bloomingdale  Hospital,  the  Phila- 
delphia General  Hospital,  the  Cook  County  Hospital  (Chicago),  the 
Latter  Day  Saints'  Hospital  (Salt  Lake  City), and  a  few  others, they 
are  either  private  sanitariums,  dependent  upon  paying  patients  for 
support,  or  else  county,  municipal,  or  State  institutions  for  chronic 
invalids  or  insane,  dependent  upon  ^public  support. 

The  patients  in  the  private  sanitariums  are  largely  drawn  from 
the  leisure  or  professional  classes.  Although  a  few  of  these  patients 
may  later  earn  their  living  as  craftsmen  or  craft  teachers,  none  of 
them  will,  in  all  probability,  enter  the  trades.  For  these  patients  the 
crafts  prove  a  resource  and  meet  all  the  needs  of  the  occupational 
therapeutist.  On  the  other  hand,  the  majority  of  the  patients  in 
public  institutions  are  so  chronically  subnormal  that  there  is  little 
hope  of  their  ever  engaging  in  competitive  industry.  The  crafts  are 
palliative  for  these  patients;  they  help  to  maintain  discipline,  and, 
in  some  instances,  they  enable  the  patients  to  earn  something  under 
direction. 

42298°— S.  Doc.  167, 


50  TRAILING  OF  TEACHERS  FOE  OCCUPATIONAL  THERAPY. 

Tims  it  is  that  the  two  types  of  institution  which  have  largely 
adopted  occupational  therapy  are  not  those  in  which  the  laboring 
classes  convalesce.  With  the  exception  of  a  few  striking  cases  of 
patients  who  have  found  their  occupational  training  in  the  convalesc- 
ing shop  to  be  of  economic  value,  the  majority  of  the  patients  of  the 
laboring  classes  who  have  had  occupational  therapy  during  con- 
valescence are  rarely^  able  to  make  any  practical  use  of  craft  training, 
and  consequently  either  return  to  their  former  trades  or  to  new 
unskilled  or  semiskilled  trades.  If  they  do  follow  their  craft  train- 
ing, their  future  is  somewhat  precarious,  for  in  such  cases  they  are 
dependent  in  a  large  degree  upon  the  fickleness  of  markets,  upon  fads, 
or  upon  the  generosity  of  the  public. 

The  economic  side  of  occupational  therapy  is  only  beginning  to  be 
appreciated.  The  report  of  the  Henry  B.  Favill  School  of  Occupations, 
the  Illinois  Society  for  Mental  Hygiene,  under  the  direction  of  Mrs. 
Eleanor  Clarke  Slagle,  shows  for  the  year  1916-17  that  25  out  of 
71  patients  were  placed  in  wage-earning  occupations  who  would, 
without  such  aid,  have  been  public  dependents,  and  that  these  pa- 
tients, together  with  those  in  attendance  in  the  department  and  the 
sales  from  their  work,  have  saved  the  State  of  Illinois  for  one  year 
$21,430.  One  hundred  patients,  moreover,  were  refused  for  lack  of 
teachers.  When  such  results  are  possible,  a  community  can  no  longer 
question  whether  it  can  afford  such  a  department,  but  rather  whether 
it  can  afford  to  be  without  it. 

The  present  limitations  of  occupational  therapy  are,  first,  overpro- 
duction of  certain  articles  dependent  upon  an  unstable  and  varying 
market,  and,  second,  failing  to  offer  training  of  economic  value  to 
the  convalescent  workingman.  In  order  to  study  how  occupational 
therapy  may,  while  retaining  all  of  its  therapeutic  value,  at  the  same 
time  reach  and  benefit  all  classes  to  the  fullest  extent,  it  will  be  neces- 
sary to  analyze  the  purposes  of  occupational  therapy.  It  is,  of  course, 
impossible  to  cover  the  specific  occupations  and  technique  of  teaching 
for  each  handicap,  as  the  range  of  disabilities  is  wide,  varying  from, 
the  most  obvious  deformity  to  the  subtlest  *psychosis  and  neurosis. 
There  are,  however,  a  few  general  principles  common  in  the  teaching 
of  all.  Occupational  therapy  aims  first  to  create  a  wholesome  interest 
in  something  outside  the  patient's  morbid  interest  in  himself  and  his 
symptoms;  second,  to  fill  the  unoccupied  portions  of  the  patient's 
day;  third,  to  prepare  his  mental  attitude  so  that  he  may  adjust 
himself  to  normal  demands  and  environment  after  hospital  dis- 
charge; and,  fourth,  to  facilitate  medical  treatment  by  regulated 
exercise. 

These  results  may  be  achieved  by  a  large  variety  of  occupations, 
and  many  practical  vocations  are  quite  as  instrumental  in  accomplish- 
ing these  as  the  crafts.  For  instance,  soldering  tin  cans,  joints,  wire, 
tinsmithing,  and  electric  wiring  involve  many  of  the  processes  used 
in  metal  craft,  and  the  manufacture  of  leather  goods,  bags,  belts, 
travelers'  cases,  and  fancy  commercial  articles  may  be  quite  as  inter- 
esting as  hand  tooling  or  illuminating.  Bookkeeping,  salesmanship, 
general  education,  stenography,  telegraphy  with  bedside  ominigraph 
may  serve  all  the  purposes  of  raffia  work,  tying  knots,  or  other  invalid 
occupations.  Furniture  making  holds  many  of  the  possibilities  of 
manual  training  and  wood  carving,  while  the  studj^  of  the  gas  engine, 


TRAINING   OF   TEACHERS  FOB  OCCUPATIONAL   THERAPY.  51 

motor  mechanics,  and  construction  work  has  an  endless  number  of 
possibilities.  Commercial  design,  architectural  drafting,  sign  paint- 
ing, lettering,  and  printing  have  many  points  in  common  with  fine- 
arts  drawing  and  painting  or  stenciling  and  block  printing.  If  the 
hospital  is  in  the  country  or  where  patients  come  from  rural  com- 
munities, lectures  and  demonstrations  of  soils,  principles  of  farm 
management,  and  sanitation  of  the  dairy  may  pass  many  a  weary 
hour.  Wherever  possible  practice  in  the  hospital  garden,  poultry 
yard,  or  orchard  should  engage  the  prescribed  exercise  rather  than 
games,  walks,  or  nature  study.  Such  activities  will  meet  all  the 
requirements,  namely,  divert  the  patients'  attention  from  himself, 
fill  his  unoccupied  time,  give  him  a  wholesome  mental  attitude,  and 
regulate  his  bodily  activity. 

There  are,  however,  real  dangers  and  drawbacks  in  introducing 
such  work  into  the  hospital  curriculum.  First,  the  danger  of  the  choice 
of  the  wrong  occupation ;  second,  the  danger  of  the  wrong  presenta- 
tion of  the  right  occupation;  and,  third,  the  harm  of  keeping  the 
patient  in  touch  with  the  same  occupation,  whose  technicalities  have 
possibly  been  the  very  grind  and  monotony  which  may  have  con- 
tributed to  his  breakdown. 

The  choice  of  the  wrong  occupation  may  have  disastrous  conse- 
quences, as  a  sound  phobia  would  be  intensified  by  telegraphy, 
nervous  exhaustion  increased  by  the  close  application  of  shorthand 
or  bookkeeping,  rheumatism,  accentuated  by  many  of  the  strained 
positions  of  gardening,  and  the  cardiac  patient  positively  in  danger 
in  a  machine  shop  with  belts  and  possible  uneven  muscular  exertion. 

If  the  right  occupation  is  selected,  any  therapeutic  value  it  might 
have  had  may  be  nullified  by  failure  to  arouse  the  patient  from  his 
apathy  or  by  overstimulation  and  exertion.  It  must  be  constantly 
borne  in  mind  that  the  patient  is  temporarily  or  permanently  sub- 
normal, that  he  is  unfit  to  acquire  training  in  regular  channels,  that 
he  comes  to  the  hospital  primarily  to  recover,  and  that  all  other 
benefits  must  remain  entirely  secondary  to  this. 

These  two  dangers  exist  no  more  for  practical  occupations  in  the 
hospital  workshop  than  they  do  for  the  so-called  crafts.  The  success 
of  occupational  therapy  does  not  lie  in  any  particular  craft  or  trade, 
but  rather  in  the  skill  with  which  it  is  selected  for  the  particular  dis- 
ability of  the  patient  and  the  technique  of  allowing  the  patient's 
reaction,  temperament,  and  fatigue  to  form  the  basis  teaching. 

The  third  danger  applies  strictly  to  practical  rather  than  to  semi- 
esthetic  occupations.  When  the  occupation  can  be  so  taught  that  it 
is  not  a  repetition  of  the  grind  that  the  man  has  been  subjected  to 
but  rather  opens  new  possibilities  to  him  and  increases  his  earning 
power,  it  is  not  to  be  weighed  in  the  balance  with  a  mere  resource, 
which  in  all  probability  the  patient  will  never  have  time  or  means  to 
enjoy.  The  further  enriching  of  the  patient's  background  by  better 
education,  by  practical  resources,  and  by  a  knowledge  of  hygienic 
living,  renders  his  convalescence  of  lasting  value. 

The  future  development  of  occupational  therapy  is  destined  to  in- 
clude all  classes  and  types  of  long  convalescent  disabilities  and  not 
only  to  assist  in  curative  treatment  but  to  take  cognizance  of  the 
industrial  world  and  to  prepare  the  handicapped,  so  far  as  is  possible, 
to  become  independent  economic  units. 


PART  III. 
SOCIAL  AND  ECONOMIC  ASPECTS  OF  OCCUPATIONAL  THERAPY. 

The  purpose  of  occupational  therapy  is  far  deeper  than  to  fill 
waste  time,  develop  mental  habits',  or  functionally  reeducate  muscles 
and  joints.  The  value  of  occupational  therapy  in  these  respects  is 
no  longer  debatable.  It  was  proved  a  sound  medical  policy  before 
the  war,  and  the  subsequent  experiences  of  the  belligerent  countries 
have  confirmed  its  earlier  claims.  But  the  social  and  economic  pos- 
sibilities of  occupational  therapy  in  the  readjustment  of  the  disabled 
to  civilian  life  are  of  immediate  importance.  In  addition,  it  is  ex- 
pedient to  know  to  what  extent  the  three  stages  of  rehabilitation, 
namely,  invalid  occupation,  occupational  therapy,  and  vocational 
education,  may  interrelate  and  contribute  to  the  ultimate  goal  of 
industrial  rehabilitation. 

ADVISABILITY  OF  PRACTICAL  WORK. 

Occupational  therapy  in  this  country  up  to  the  present  has  made 
no  invasion  into  the  field  of  vocational  education.  There  are  a  few 
striking  exceptions  of  men  who  have  been  better  equipped  for  work 
after  a  hospital  experience,  but  these  cases  are  unfortunately  rare. 

The  occupations  selected  for  the  workshops  have  been  largely  crafts. 
Difficulty  has  been  experienced  in  marketing  the  patients'  handiwork 
and  in  providing  them  with  a  future  occupation  which  may  follow 
if  unable  to  compete  in  the  usual  lines  of  industry.  These  economic 
limitations  have  reacted  upon  the  patients  in  many  instances  to  such 
an  extent  that  the  full  value  of  occupational  therapy  has  not  been 
realized.  As  Dr.  Frederic  Brush  has  said : 1 

Success  in  mental  convalescence  is  going  to  hinge  on  occupation,  and  occupa- 
tional therapy  is  measurably  failing  everywhere  because  of  lack  of  sales  outlets 
for  its  products. 

Dr.  Thomas  "\V.  Salmon  2  has  expressed  the  same  thought : 

Nonproductive  occupations  are  not  only  useless  but  deleterious.  The  principle 
of  "  learning  by  doing  "  should  guide  all  reeducative  work.  "  Continual  resting," 
long  periods  spent  alone,  general  softening  of  the  environment,  and  occupations 
undertaken  simply  because  the  mood  of  the  patient  suggests  them  are  positively 
harmful,  as  shown  by  the  poor  results  obtained  in  those  general  hospitals  and 
convalescent  homes  in  which  such  measures  are  employed. 

Experience  in  Europe  has  proved  that  if  trivial  and  time-passing 
occupations  are  too  long  continued  in  the  rehabilitation  of  disabled 
soldiers  and  sailors,  men  have  been  actually  turned  away  from  pro- 
ductive occupations  and  have  taken  up  one  of  those  "semitrades" 


1  The  Convalescent  Field — Us  New  and  Changing  Border  Lines. 
"  Psychiatric  Bulletin  of  the  New  York  State  Hospitals,  July,  1917. 


52 


TRAINING   OF   TEACHERS  FOR  OCCUPATIONAL  THERAPY.  53 

which  are  dependent  upon  charity  or  upon  uncertain  and  fickle  mar- 
kets for  support.  Trinkets  made  by  convalescent  soldiers  in  France 
sold  at  prices  far  in  excess  of  their  actual  value.  Whatever  ambition 
the  men  might  have  had  for  practical  work  was  thus  paralyzed  and 
they  continued  to  make  these  trifles  long  after  they  were  physically 
able  to  perform  work  of  a  different  type.  The  result  was  that  the 
men's  infirmities  were  capitalized  and  they  were  made  dependents 
on  public  beneficence. 

In  Germany  it  is  provided  that  there  shall  be  no  waste  of  time  on 
useless  occupations.  The  Krupps  firm  at  Essen  have  established  a 
curative  Avorkshop  for  disabled  men  under  medical  supervision.  Dr. 
Tjaden  said  in  a  lecture  in  Bremen: 

The  systematic  influencing  of  the  invalid's  will  power  is  of  the  greatest  im- 
portance. *  *  *  TO  employ  the  invalid  for  any  length  of  time  on  trivial 
work  does  not  seem  suitable.  It  is  much  better  to  employ  him  at  gainful  work 
as  soon  as  possible  and  to  arouse  in  him  consciousness  that  he  still  is  able  to 
perform  efficient  work. 

Herbert  Corey  thus  describes  German  methods  of  reeducation: 

The  plan  is  to  make  every  man  self-supporting  after  the  war,  no  matter  how 
little  of  him  may  be  left.  It  is  infinitely  better  for  the  man  and  for  Germany 
when  the  \var  ends.  The  Germans  never  forget  the  hideous  nightmare  of  their 
present  existence.  It  is  recognized  that  the  work  of  every  hand  will  be  needed. 
The  man  who  has  but  one  hand  must  be  fitted  to  do  his  part  for  his  country'* 
sake  if  not  for  his  own. 

During  the  latter  part  of  the  stay  in  the  hospital  of  these  torn  and  broken 
men  they  are  carefully  studied  by  the  men  who  have  made  themselves  experts 
to  meet  this  exigency.  Their  intelligence,  their  education,  their  nervous  re- 
actions, everything  about  them  is  card  indexed  and  tested.  *  *  * 

When  they  have  gained  enough  strength,  the  training  for  their  future  life 
work  is  begun.  Practical  Germany  never  wastes  time  on  raffia  and  leather 
working  and  souvenir  boxes  and  the  rest  of  the  tragic  uselessness  that  the 
maimed  men  is  too  often  set  adoing.  The  German  theory  is  that  there  is  no 
active  market  for  hideously  ugly  bags  made  out  of  knotted  cord,  or  for  hand- 
hammered  tin  biscuit  boxes  which  counterfeit  unconvincingly  a  silversmith's 
handiwork.  Furthermore,  the  German  theory  is  that  the  maimed  man  realizes 
this  and  that  the  heart  is  taken  out  of  him  by  it.  If  he  can  do  something — 
even  a  very  little  thing — which  is  of  real  use  in  the  world,  he  chirks  up  and  is 
happy.  But  if  he  feels  himself  condemned  to  be  an  object  of  charity  for  all 
his  remaining  days,  the  heart  dies  in  him. 

So  that  whatever  it  is  the  inutile"  is  trained  to  do,  it  is  at  least  practical  and 
salable.  He  may  only  have  one  arm  left  of  his  original  complement  of  limbs, 
but  the  poor  remnant  of  \vhat  was  once  a  man  can  still  run  a  lathe.  A  man 
without  arms  and  with  only  one  leg  is  able  to  run  a  heavy  press  in  a  Bavarian 
factory,  since  it  is  directed  by  foot  treadles.  The  training  is  conducted  by  real 
"  efficiency  experts,"  who  develop  the  last  ounce  of  capacity  in  the  man  and  who 
are,  of  course,  aided  by  the  impassioned  effort  of  the  man  himself,  for  he  is 
invariably  pathetically  anxious  to  make  himself  a  really  valuable  producing 
member  of  society  again. 

Many  of  these  men,  according  to  my  information  from  German  sources,  are 
earning  more  money  than  they  did  before  the  \var.  Very  few,  indeed,  have 
had  to  be  abandoned  as  wholly  useless  wreckage,  to  be  supported  by  public 
charity  until  death  shall  release  them.  None  of  the  mutil£s  are  released  from 
the  army  until  their  training  has  been  completed,  in  order  that  they  may  be 
held  under  rigid  discipline  during  the  training  period. 

The  expediency  of  commencing  vocational  education  in  the  hospi- 
tals has  been  established  by  the  experience  of  France,  Canada,  and 
Belgium.  It  has  been  found,  moreover,  that  the  men  respond  far 
better  to  work  of  a  practical  type  in  the  curative  workshop  than  to 
time-passing  or  trivial  occupations.  These  have  served  their  func- 
tions in  invalid  occupations  by  lessening  the  long  hours,  preparing 


54  TEAIXIXG  OF   TEACHEBS   FOR   OCCUPATIONAL   THEKAPY. 

the  patient's  mind  for  real  work,  and  in  many  cases  actually  giving 
practical  work  in  general  education  and  simple  processes  which  lead 
directly  to  work  of  a  more  complex  character  in  the  curative  work- 
shop. In  order  that  the  handicapped  man  may  be  really  convinced 
that  there  is  a  future  of  economic  independence  ahead  of  him  he  must 
feel  that  he  is  doing,  however  inadequately,  "a  man's  job"  from  the 
earliest  possible  moment. 

Before  the  vocational  education  was  introduced,  many  of  the  men  dreaded  to 
be  discharged  and  cut  off  from  military  pay  and  allowance,  but  since  the  classes 
have  been  well  established  some  men  who  have  gained  new  wage-earning  ability 
from  their  acquired  technical  knowledge  often  welcome  their  discharge  and 
boldly  step  into  better  positions  than  they  ever  occupied  before.1 

While  the  work  is  intended  primarily  to  be  curative  for  mind  and 
body,  experience  has  shown  that  many  men  with  the  development  of 
mechanical  skill  have  attained  the  ability  to  interpret  blue  prints,  a 
knowledge  of  shop  arithmetic  and  mechanical  drawing,  and  that  they 
have  actually  increased  their  commercial  value  in  after  life. 

These  things  can  be  and  are  being  imparted  to  men  in  the  convalescent  hospi- 
tals, and  cases  have  already  occurred  in  which  men  have  returned  to  civil  life 
and  taken  better  positions  than  they  held  before  enlistment  in  consequence  of 
the  training  received  during  convalescence." 

In  some  cases  this  educational  work  in  the  convalescent  home  has  been  of 
such  value  to  the  men  taking  it  that  they  have  secured  positions  that  pay  them 
50  to  100  per  cent  more  than  the  ones  which  they  filled  prior  to  enlistment.0 

The  Dilution  of  Labor  Bulletin  4  of  the  British  Ministry  of  Muni- 
.tions  states  that  the  handicapped  men  have  passed  from  training 
into  employment  as  gauge  makers,  tool  setters,  tool  turners,  tool 
hardeners,  viewers,  molders,  millers,  and  core  makers,  skilled  turners, 
fitters,  capstan  hands,  aero  erectors  and  assemblers,  sheet-metal  work- 
ers, and  press  workers. 

The  instruction  in  turning  usually  has  included  screw  cutting,  tool 
setting  for  capstans  and  machines,  others  have  learned  the  use  of 
plain,  universal  millers,  grinders,  cylindrical  cutter  grinders,  shapers, 
etc.  They  learn  molding,  aluminum  castings,  and  make  heavy  and 
complicated  cores. 

In  Canada  men  have  become  concrete  and  sanitary  inspectors  as  a 
result  of  training,  and  in  Italy  as  well  as  Canada  the  men  are  learn- 
ing to  operate  motor  tractors  instead  of  plows.  In  England  they  are 
learning  to  make  and  repair  shoes  by  machinery  instead  of  the  old- 
fashioned  and  overcrowded  trade  of  cobbling. 

The  need  for  trained  oxy-acetylene  welders  hae  been  felt  in  every 
country.  Oxy-acetylene  welding  is,  moreover,  possible  for  men  with 
leg  disabilities  and  for  the  one  armed,  provided  there  is  strength  in 
the  remaining  arm  to  move  the  blowpipe  over  continuously  long 
periods  of  time  and  provided  that  the  artificial  arm  can  manipu- 
late filling  material  if  such  is  necessary.  In  Germany  in  1916 
Mr.  Theodore  Kautny,  director  of  the  Royal  School  for  Machine 
Building  in  Cologne,  had  trained  50,000  men  disabled  from^the 
front  to  be  expert  oxy-acetylene  welders.  He  devised  a  lightweight 
blowpipe  for  the  use  of  these  men.  They  were  called  "  Kautny 's 

1  Military   Hospitals  Commission  of  Canada  Report,  May,   1917. 

2  Monthly  Review  of  the  U.  S.  Bureau  of  Labor  Statistics,  October,   1917. 

3  L.  V.  Sharp,  iu  American  Journal  of  Care  for  Cripples,  Vol.  IV,  No.  2. 
"Vol.   II,   No.   1. 


TRAINING   OF    TEACHEES   FOE    OCCUPATIONAL   THERAPY.  55 

army."  Great  Britain  has  made  a  study  of  courses  and  methods  for 
training  her  disabled  for  this  important  service.  A  serious  shortage 
of  oxy-acetylene  welders  at  the  beginning  of  the  war  faced  this  coun- 
try. Not  only  are  welders  greatly  in  demand  but  the  training  is  par- 
ticularly suitable  for  many  cases  in  the  curative  workshop.  These 
men  will  render  valuable  service  back  of  the  lines,  and  they  will  also 
be  skilled  in  an  occupation  which  is  destined  to  be  of  commercial 
value. 

Polishing  glass  for  asphyxiating-gas  masks  and  lens  grinding  are 
other  occupations  practical  for  some  curative  workshops. 

By  proper  organization  of  tlie  reconstruction  hospital  this  vocational  training 
can  be  instituted  as  soon  as  the  patient  is  able  to  leave  his  bed,  and  by  the 
time  he  is  ready  to  leave  the  hospital  properly  equipped  with  an  artificial  limb, 
he  is  also  properly  equipped  for  his  trade  or  profession.  Using  the  workshop  as 
a  form  of  medical  treatment  is  one  of  the  many  ways  in  which  the  various 
departments  of  the  hospital  dovetail  into  one  another  and  justify  its  existence 
as  an  organic  whole.1 

REMUNERATION  OF  MEN  IN  WORKSHOPS. 

The  remuneration  of  men  doing  work  of  commercial  or  marketable 
.value  in  the  curative  workshop  or  vocational  schools  offers  a  difficult 
problem.  Proper  recompense  has  been  found  to  stimulate  the  men. 
On  the  other  hand,  competition  between  men  of  different  capabilities 
and  with  different  degrees  of  handicap  is  obviously  unwise.  Fur- 
thermore, a  man's  future  productivity  may  be  increased  by  perform- 
ing work  of  no  commercial  value  during  training  and  so  a  premium 
should  not  be  placed  on  immediate  returns. 

There  are  difficulties  of  bookkeeping  and  also  of  the  disposal  of  the  articles 
made,  where  large  numbers  of  men  are  concerned.  There  is  also  the  serious 
danger  of  the  goods  being  sold  on  a  compassionate  basis,  and  not  at  market 
prices.  Also,  if  large  quantities  are  produced  for  sale,  there  is  the  probability 
of  protests  similar  to  those  made  against  the  sale  of  prison-made  goods  being 
made  ;i gainst  the  sale  of  articles  produced  in  the  convalescent  hospital  work- 
shop.2 

When,  however,  certain  disabilities  are  grouped  together  in  special 
institutions,  as,  for  instance,  the  insane,  the  war  neuroses,  the  tuber- 
cular, the  blind,  etc.,  and  work  of  a  commercial  value  is  prescribed,  it 
is  desirable  that  the  men  should  receive  some  remuneration  within 
these  narrow  limits. 

At  the  Grand  Palais  in  France  the  men  are  paid  2  cents  an  hour, 
increasing  to  4.1  cents.  They  work  for  the  army  or  the  public  or 
their  work  is  sold  commercially.3  In  Italy  the  soldier  receives  about 
20  cents  a  day  for  his  work  in  training. 

In  the  workshops  of  the  Eoyal  Orthopedic  Reserve  Hospital  at 
Nurnberg  4  a  clever  method  of  remunerating  the  men  and  at  the  same 
time  preventing  unfair  competitive  struggle  has  been  worked  out. 
The  payment  for  work  which  is  sold  is  based  upon  the  usual  rate  of 
pay  per  hour.  Instead  of  giving  the  money  to  the  patients  a  notice 
is  posted  in  each  shop  reading :  "  Your  earnings  will  be  used  for  the 
benefit  of  war  invalids."  In  the  Krupp's  curative  workshop  at  Essen 

1  Dr.  TLeo  Mayer,  in  American  Journal  of  Care  for  Cripples,  Vol.  V,  No.  1. 

2  T.  B.  Kidner,  address  in  Boston.  Nov    15    1917. 

3  Monthly  Review,  U.  S.  Bureau  of  Labor  Statistics,  June,  1917. 
*  American  Journal  of  Care  for  Cripples,  Vol.  IV,  No.  2. 


56  TRAIXIXG    OF    TEACHERS   FOB    OCCUPATIONAL   THERAPY. 

the  men  receive  special  allowances  and  in  addition  the  customary  rate 
of  wages  for  all  useful  work. 

New  Zealanders  undergoing  training  in  England  are  not  permitted 
to  receive  pay  from  employers  on  the  ground  that  they  have  not  been 
discharged  from  the  army.  The  labor  unions  made  trouble  over  em- 
ployer's nonpayment  privileges,  and  it  was  decided  to  pay  their 
wages  to  charity. 

In  Canada  in  the  carpenter  shops  of  the  military  hospitals  com- 
mission 25  per  cent  of  the  retail  price  of  the  article  is  taken  for 
material  and  overhead  expenses  and  the  remaining  75  per  cent  goes 
to  the  soldier  pupil.  It  is  provided  that  the  soldiers  may  draw  20 
er  cent  of  their  earnings,  80  per  cent  being  reserved  for  a  fund  to 
e  given  them  on  discharge.  The  patients  receive  work  for  repair- 
ing in  the  shoe  shop,  and  those  who  take  training  in  agriculture  in 
Alberta  receive  returns  from  gardens  and  poultry  yards. 

In  one  district  the  proceeds  (from  the  men's  work)  are  put  into  a  common 
fund,  managed  by  a  committee  of  officials  and  patients,  the  fund  being  used 
to  purchase  extras  of  various  kinds  for  the  men  themselves.  From  another 
center  there  has  just  come  in  a  suggestion  that  army  profits  accruing  shall  be 
handed  to  the  Red  Cross  funds.  My  personal  opinion  is  that  if  it  be  possible 
to  arrange  it  a  man  who  is  industrious  should  receive  some  monetary  benefit 
from  his  labor.1 

Dr.  Leo  Mayer  believes  it  best  to  pay  the  men  a  small  gratuity 
and  give  them  the  benefit  of  the  proceeds  from  the  sales  of  articles 
made  by  them. 

MARKETABLE  PRODUCTS. 

AH  far  as  is  consistent  with  work  prescriptions  and  vocational 
education  it  is  desirable  to  have  the  men  make  marketable  products. 
Armature  winding  and  insulation  of  electrical  equipment,  mas- 
saging, and  telephone  operating  with  drop-shutter  system  have  been 
found  practical  for  the  blind.2  Massage  tables,  bed  trays,  hospital 
furniture,  supplies,  and  repairs  may  be  made  in  the  workshops. 
Necessary  plumbing,  painting,  glazing,  carpentry,  tailoring,  and  up- 
keep of  automobiles  about  the  hospitals  should  be  included  in  shop 
instructions.  Many  men  may  be  used  in  making  artificial  appliances 
in  the  curative  workshop  of  an  orthopedic  hospital. 

The  foreign  countries  have  combed  the  United  States  for  makers 
of  artificial  arms  and  legs.  It  was  found  that  one  firm  preferred  to 
employ  crippled  men  in  the  making  of  prosthetic  appliances,  for  the 
reason  that  they  made  the  most  intelligent  workmen,  and  their 
own  experience  afforded  many  helpful  suggestions.  Canada  has  es- 
tablished a  factory  at  the  new  orthopedic  hospital  in  North  Toronto. 
The  military  hospitals  commission  found  it  necessary  to  train  its 
own  limb  makers.  Whenever  possible  men  who  wear  artificial  limbs 
are  being  taught  and  employed  in  the  factory.  As  the  limbs 
have  to  be  repaired  and  overhauled,  it  is  desirable  that  the  men 
wearing  them  be  acquainted  with  their  mechanism,  so  they  may 
make  minor  repairs  themselves.  Especially  is  this  desirable  for  the 
men  in  rural  districts  who  are  far  distant  from  a  source  of  repair. 
The  commission  has  a  decided  advantage  in  taking  hold  of  the 

1  T.  B.  Kidnor.  in  an  address  given  In  Boston,  Nov.  15,  1917. 

2  After  a  few  days'  training  those  men  are  able  to  earn  $2  per  day  on  electrical  planls. 
The  masseurs  receive  $12.13  a  week. 


TRAINING   OF   TEACHERS  FOR  OCCUPATIONAL  THERAPY.  57 

problem.  The  commission  is  able  to  secure  the  most  up-to-date  im- 
provements, by  arrangement  with  various  patentees,  and  is  in  a  posi- 
tion, should  any  patentee  refuse  to  lease  his  rights,  to  require  him  to 
do  so  and  to  submit  the  matter  to  arbitration. 

There  is  a  considerable  profit  in  the  manufacture  of  limbs,  a  large  propor- 
tion of  which  is  devoted  by  the  makers  to  advertising  and  sale,  neither  of  which 
charges  would  fall  upon  the  commission  in  connection  with  its  own  factory.1 

In  a  Vienna  hospital  controlled  by  Prof.  Spitzy  no  soldier  with 
an  amputation  is  given  discharge  until  he  has  served  four  weeks 
in  the  department  where  artificial  limbs  are  made  and  has  received 
a  certificate  showing  he  can  repair  his  own  appliances.  The  ablest 
men  are  retained  in  the  shop  to  be  the  teachers  of  new  patients. 

Here,  then,  is  a  practical  and  useful  occupation  for  that  group 
of  convalescents  in  the  curative  workshops  who  need  the  therapeutic 
effect  of  work,  but  who  do  not  need  vocational  training,  and  who 
will  need  to  know  how  to  repair  and  keep  their  own  appliances  in 
order.  Inasmuch  as  there  was  a  shortage  of  brace  makers  before 
the  war,  and  as  most  of  them  have  gone  to  France  and  England,  the 
manufacture  of  artificial  appliances  opens  a  real  profession  for  many 
of  the  disabled,  at  the  same  time  filling  a  national  need. 

Dr.  Salmon  suggests  for  the  workshops  of  patients  with  neuroses 
that— 

It  is  desirable  to  begin  with  a  few  absolutely  necessary  things  and  to  add 
those  made  by  the  patients  themselves.  When  this  is  done  every  piece  of  appa- 
ratus is  invested,  in  the  eyes  of  the  patients,  with  the  spirit  of  achievement 
through  persistent  effort — the  very  keynote  of  treatment.  The  fact  that  it  has 
been  made  by  the  patient's  recovering  from  neuroses  will  help  hundreds  of  sub- 
sequent patients  through  the  force  of  hopeful  suggestion.3 

This  seems  especially  desirable  in  the  workshops  for  the  war 
neuroses  and  psychoses,  where  the  percentage  of  officers  is  relatively 
high  and  where  they  will  return  more  probably  to  the  professions 
than  to  the  trades.  "Here,  training  is  therapeutic  rather  than  voca- 
tional. 

OVERLAPPING  OF   STAGES   OF  REHABILITATION. 

Occupational  therapy  in  the  rehabilitation  of  the  disabled  forms 
the  vital  link  between  medical  treatment  and  vocational  education. 
Medical  treatment  without  occupational  therapy  and  vocational  edu- 
cation is  powerless  to  accomplish  industrial  rehabilitation.  Voca- 
tional education,  on  the  other  hand,  can  not  effect  rehabilitation  after 
the  completion  of  medical  treatment  unless  the  patient's  mind  was 
prepared  during  convalescence  by  definite  occupation  so  that  he 
wishes  to  become  a  productive  citizen.  So  important  a  place  has  it 
come  to  hold  in  the  treatment  of  war  invalids  that  the  following  reso- 
lution was  passed  by  the  interallied  conference  held  in  Paris  May 
8-12,1917: 

In  view  of  the  constancy  of  the  psychic  factor  in  all  matters  relating  to  tech- 
nical reeducation  of  the  disabled,  it  is  necessary  in  reeducation  to  unite  psycho- 
therapeutics  with  physiotherapeutics  and  to  recognize  the  psychotherapeutic 
value  of  technical  works.  (Resolution  No.  41.) 

1  Military  Hospitals  Commission  of  Canada  Report,  May,  1917. 

2  Psychiatric  Bulletin,  New  York  State  Hospitals,  July,  1917. 


58  TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL   THERAPY. 

At  the  same  conference — 

All  delegates  were  agreed  on  the  necessity  of  having  all  physical  training 
and  treatment  under  strict  medical  supervision  until  such  time  as  the  patient 
is  ready  to  be  sent  back  to  the  Army  in  some  capacity  or  another,  or,  if  judged 
unfit  for  military  service,  is  ready  to  begin  reeducation  of  a  purely  professional 
kind. 

The  curative  workshop  is  directly  under  the  supervision  of  the 
medical  authorities.  The  most  cordial  cooperation  between  the  physi- 
cian and  the  occupation  instructor  is  necessary  in  order  to  secure  the 
best  results  in  rehabilitation. 

Training  and  secondary  treatment  are  interdependent,  and  at  least  in  the 
earlier  stages  the  training  should  be  supervised  by  medical  experts.1 

Vocational  reeducation  prolongs  and  completes  functional  reeducation.  They 
constitute  together  an  undeniable  physiological  unity,  but  it  is  necessary  that 
they  form  a  psychological  union  in  the  sense  that  the  wounded  should  be 
prepared  from  the  hospital  for  his  future  career." 

Close  collaboration  between  doctor  and  technical  advisor  fe  indispensable  for 
complete  reeducation ;  it  is  also  indispensable  for  guiding  the  injured  man  and 
starting  him  on  sound  lines  from  the  outset  of  reeducation.  Reeducation  must 
follow  immediately  after  medical  treatment  and  even  overlap  it.8 

CONTRIBUTIONS    OF    VOCATIONAL    EXPERT. 

Since  reeducation  overlaps  medical  treatment,  since  work  pre- 
paratory to  vocational  education,  and  even  vocational  education 
itself,  exists  in  the  curative  workshop,  and  since  these  men  must  be 
guided  from  the  first  toward  their  future  careers,  it  is  necessary  that 
the  vocational  officer  be  consulted  as  soon  as  the  patient's  general 
condition  is  good  and  prognosis  fairly  certain,  otherwise  there  will  be 
a  tremendous  waste  of  time,  energy,  and  money. 

The  men  have  been  recruited  from  widely  diversified  interests, 
occupations,  and  environments.  They  vary  moreover  in  education, 
experience,  and  natural  intelligence.  The  choice  of  an  occupation, 
new  or  old,  is  a  matter  of  serious  consideration  and  must  be  jointly 
decided  by  the  medical  and  vocational  officers.  Once  the  patient's 
vocation  is  determined  upon,  or  several  occupations  are  suggested  for 
observation  or  practice  in  the  curative  workshop,  it  then  becomes  the 
duty  of  the  occupational  therapeutist  to  train  the  patient  in  those 
lines  in  so  far  as  they  are  consistent  with  the  physician's  instructions. 

Appendix  V  suggests  blanks  for  charting  the  patient's  vocational 
history,  his  record  in  the  curative  workshop,  his  vocational  training 
at  hospital  discharge,  and  his  later  record  in  the  vocational  school, 
if  such  is  necessary. 

The  convalescent  patient  begins  with  short  periods  of  work,  and 
as  his  recovery  progresses  the  time  required  for  medical  treatments 
decreases,  while  the  time  for  work  increases.  Just  as  occupational 
therapy  utilizes  the  waste  time  between  medical  treatments  and  be- 
comes more  and  more  important  as  the  patient  recovers,  so  the  duties 
of  the  vocational  experts  become  increasingly  important.  It  might 
be  said  that  early  in  the  convalescence  the  medical  treatment  is  the 
chief  concern,  and  as  it  diminishes  in  importance  as  the  patient 

1  L.  O.  Brock.  In  American  Journal  of  Carp  for  Cripples,  Vol.  IV,  No.  1. 

2  Translated  from  Organisation  rhysiologrique  du  Travail,  by  Jules  Amur. 

3  Bulletin  No.  1.  Aunee  101G,  Office  National  des  Mutile's  et  re"formes  de  la  Guerre. 


OF   TEACHEBS  FOE  OCCUPATIONAL  THERAPY.  59 

recovers,  the  value  of  training  increases  in  proportion,  so  that  at  the 
close  of  convalescence  and  hospital  discharge  training  is  the  primary 
concern.  From  this  point  the  patient  enters  either  a  civilian  occupa- 
tion or  a  regular  vocational  school  no  longer  under  medical  authority. 

In  orthopedic  cases  it  will  be  necessary  for  the  vocational  expert 
to  be  present  when  the  functional  power  of  a  limb  is  determined 
by  Amar's  or  other  tests.  From  these  readings  and  the  predictions 
of  the  doctors  as  to  the  patient's  future  physical  condition,  the  voca- 
tional expert  must  decide  upon  that  occupation  which  is  best  suited 
to  his  infirmities. 

In  cases  of  amputation,  such  tests  as  Prof.  Amar's  are  of  great 
value.  The  purpose  of  Amar's  tests  is  to  determine: 

I.  The  fitness  of  the  stump  for  reeducation. 
II.  The  amount  of  power  in  it. 

Measured  by  laboratory  experiments. 
Arthrodynamometer.    1 

C5"Cle-  moments  used  for  test, 

Dynamograph. 

III.  Condition  of  senses,  sight,  touch,  hearing. 

IV.  Condition  of  heart,  lungs,  nerve  centers. 

Test   to   measure  respiratory  changes   as  indicating  degree  of 

fatigue  to  which  patient  is  subjected. 
V.  State  of  reflexes — speed  or  reactions — coordination. 

The  result  of  Amar's  tests  show  that  80  per  cent  of  the  maimed  or 
mutilated  are  capable  of  reeducation.  Of  these  45  per  cent  are  totally 
reeducable  with  specialization,  20  per  cent  are  partially  so  and  15 
per  cent  fragmentarily.  Future  discouragements,  makeshifts,  and 
misfits  are  reduced  to  the  minimum  by  the  actual  knowledge  of  the 
power  and  strength  of  the  man.  Functional  abnormalities  are  over- 
come as  far  as  possible  and  resistance  to  fatigue  increased  to  the 
maximum  before  placement  is  attempted.  Permanency  and  suc- 
cess logically  follow. 

The  question  of  prosthesis  is  closely  connected  with  that  of  vocational  re- 
education, for  without  comfortable  artificial  limbs  the  maimed  can  do  no  work. 
It  is  an  art,  or  a  science,  which  has  progressed  greatly  during  the  war.1 

A  considerable  period  of  time  must  elapse  between  the  amputation 
and  the  final  fitting  of  the  artificial  member  or  the  completion  of 
functional  reeducation.  This  period  will  prove  of  value  both  to  the 
medical  and  vocational  expert  in  helping  to  determine  the  man's 
physical  future  through  observation  of  his  methods  and  disposition 
in  the  hospital  workshop.  Since  the  purpose  of  all  appliances  is  to 
enable  the  man  to  follow  either  his  old  occupation  or  learn  a  new 
one,  it  is  well  to  know  at  the  time  of  selection  for  what  occupation 
the  appliance  will  be  used.  Inasmuch  as  the  ^occupation  is  Deter- 
mined by  the  vocational  expert,  his  cooperation  at  the  point  of 
selecting  the  appliance  is  most  necessary.  For  instance,  from  the 
vocational  point  of  view  there  are  several  points  to  be  considered 
in  the  selection  of  artificial  arms.  There  is,  first,  the  necessity  of 
any  appliance  at  all,  since  many  patients  can  best  adapt  themselves 
to  some  occupations  without  an  appliance.  Second,  the  effect  on 
the  appliance  of  possible  devices  in  machinery  and  modifications  in 

1  M.  H£vys,  Paris,  in  American  Journal  of  Care  for  Cripples,  Vol.  IV,  No.  2. 


60  TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL   THERAPY. 

tools.  Third,  the  question  whether  the  type  of  appliance  1  shall  be 
simple,  durable,  light,  or  mechanical,  according  to  the  work  it  will 
be  called  upon  to  perform.  Fourth,  the  question  of  the  nearness  of 
the  patient  to  centers  of  manufacture  for  repairs  on  complicated 
apparatus. 

(a)  Occupational  direction. — The  vocational  expert  has  a  distinct 
contribution  to  make  toward  rehabilitation.  Together  with  the 
doctor,  after  consulting  the  patient  for  his  preferences  and  interests, 
he  must  decide  what  occupation  had  best  be  followed.  The  doctor 
knows  his  physical  limitations,  the  probable  effect  of  that  limitation 
upon  his  general  health,  the  greater  handicap  of  increasing  years  and 
recurrent  illnesses.  The  vocational  expert,  on  the  other  hand,  knows 
the  industrial  handicap  which  the  patient's  disability  will  prove  in 
competition  with  normal  workers.  In  the  choice  of  an  occupation 
he  will  aim  to  utilize  to  the  full  the  man's  intelligence  and  the  sound 
members  of  his  body,  rather  than  to  depend  upon  the  reeducation  of 
a  doubtful  member.  In  many  cases  the  wisest  training  will  be  to 
make  skillful  left-handed  men,  rather  than  to  reeducate  an  impaired 
right  arm  or  trust  to  an  appliance. 

In  the  main  the  one-armed  must  be  led  away  from  manual  occu- 
pations. An  artificial  arm  reduces  output  about  25  per  cent.  It  is 
different  with  artificial  legs.  Men  ^  with  amputated  legs  can  stand 
at  their  work,  provided  the  amputation  was  below  the  knee.  Lesions 
of  limbs  frequently  require  more  careful  selection  of  trades  than 
in  the  case  of  amputated  limbs.  Men  with  head  injuries  should  be 
placed  so  that  there  may  be  no  accident  through  dizziness  and  so 
that  the  posture  does  not  aggravate  the  lesion.  The  handicapped 
should  avoid  occupations  which  have  increased  liability  to  accident 
and  are  hazardous  for  a  remaining  member,  such  as  grinding  for 
a  man  with  one  eye  and  stamping  for  a  one-armed  man.  The  voca- 
tional expert  must  decide  whether  the  patient  will  be  best  able  to 
continue  his  former  occupation  or  undertake  a  new  one,  in  the  light 
of  his  former  occupation,  education,  experience,  social  status,  natural 
intelligence,  and  other  characteristics.  Whenever  possible,  the  man 
should  be  directed  into  a  former  occupation  so  that  all  possible  use 
may  be  made  of  his  past  experience. 

The  men  for  whom  training  will  be  necessary  in  new  occupations 
are,  first,  those  who  have  been  previously  employed  in  heavy  trades 
or  in  those  in  which  their  disability  makes  it  impossible  for  them  to 
continue;  second,  those  who  before  the  war  have  been  employed  on 
juvenile  trades;  third,  those  who  have  shifted  about,  working  at  dif- 
ferent jobs  and  unable  to  do  any  one  thing  well ;  and,  fourth,  those 
who  before  the  war  were  classed  as  "  unemployable  "  except  in  times 
of  labor  scarcity.  Of  the  last  class  it  has  been  said  that  if  they  could 
be  put  under  military  discipline  and  made  to  learn  a  trade  they 

1 "  The  French  have  two  arms,  one  for  strength  and  one  for  skill."  Jules  Amar, 
Acadeinie  des  Sciences  Comptes  Rendes,  1916,  v.  102.  The  following  devices  are  noted 
in  the  American  Journal  of  Care  for  Cripples,  Vol.  IV,  No.  2  : 

1.  Grip  designed  to  hold  tool  in  any  position.     Modification  enables  mechanic  to  hold 
screw  driver,  hammer,  and  file  (three  different  positions). 

2.  Gauntlet  for  cases  of  musclo-spiral   paralysis. 

3.  Socket  and  stirrup  for  digging  equipped  with  joint  for  raising  and  lowering. 

4.  Clip  and  block  for  stitching  and  putting  covers  on  books. 

5.  Loom  fitted  for  one-armed. 

€».   Stitching  pad  for  boot  work  for  man  without  a  sound  knee  to  press  against. 
Resolution    89c    of    the    interallied    conference,    passed    May    11.    1917,    provides    that 
"  blind  men  who  have  lost  an  arm  will  receive  the  special  knife  invented  by  M.  L,otz." 


TRAINING   OF   TEACHERS  FOR  OCCUPATIONAL  THERAPY.  61 

would  become  productive  instead  of  a  drain.  Government  control 
affords  an  opportunity  to  teach  these  men. 

When  a  new  occupation  is  selected  it  should  be  one  whose  processes 
are  kindred  to  the  old  trade  and  whose  tools  and  raw  materials  will 
be  as  familiar  to  the  worker  as  practicable.  If  the  patient  comes 
from  a  rural  community  or  if  he  will  undertake  an  agricultural 
course,  he  should  be  persuaded  to  do  so.  The  skilled  trades  offer  the 
best  possibilities  for  permanent  employment.  Unemployment  is  seri- 
ous for  the  handicapped  since  they  can  not  easily  adjust  themselves 
to  the  shiftings  of  the  labor  market.  Only  those  men  who  are  in- 
capable of  becoming  skilled  should  be  absorbed  in  the  unskilled  or 
semiskilled  trades.  The  vocational  expert  knows  what  training  will 
be  adequate  to  prepare  the  patient  for  the  selected  occupation  and 
what  results  may  be  anticipated  upon  the  completion  of  training. 
He  is,  moreover,  familiar  with  the  trades  and  knows  those  which  re- 
quire degrees  and  kinds  of  muscular  exertion  as  well  as  those  in  which 
there  is  dust,  noise,  fumes,  vibration,  dampness,  dryness,  exposure, 
and  extremes  or  unevenness  of  temperature.  The  vocational  man 
understands  the  opportunities  for  employment,  for  he  knows  what 
trades  are  standard,  seasonal,  and  least  crowded.  When  vocational 
experts  have  not  directed  the  careers  of  the  patients  such  serious  mis- 
takes have  been  made  as  that  of  France  permitting  90  per  cent  of  the 
wounded  from  rural  communities  to  train  for  clerical  positions.  An 
active  propaganda  designed  to  attract  returning  men  to  the  land  is 
attempting  to  overcome  this  early  blunder. 

(b)  Classification  of  duties  of  vocational  expert. — The  following 
classification  indicates  the  duties  of  the  vocational  expert  in  relation 
to  each  group.  He  must  know  in  advance  which  patients  require  only 
placing  and  which  need  either  occupational  therapy,  vocational  edu- 
cation, or  both: 

1.  Disabled  for  service.    Able  to  return  to  former  work  or  work  for  which  they 

need  no  vocational  training. 
A.  Placement. 

2.  In  need  of  further  medical  treatment.    Upon  discharge  will  be  able  to  follow 

former  occupation  or  take  up  new  without  vocational  training. 

A.  Occupational  therapy. 

B.  Placement. 

3.  In  need  of  no  further  medical  treatment  but  unable  to  follow  former  occupa- 

tion and  new  vocation  necessary. 

A.  Vocational  training. 

B.  Placement. 

4.  In  need  of  further  medical  treatment  and  new  vocation. 

A.  Occupational  therapy  or  prevocational  training. 

B.  Vocational  training. 

C.  Placement. 

5.  In  need  of  permanent  medical  supervision  or  unable  to  compete  in  any  regu- 

lar vocation.    Not  totally  disabled  for  special  and  limited  work. 

A.  Occupational  therapy  until  cured  as  far  as  possible. 

B.  Placement  in  workshop  specially  provided  for  this  class. 

CONTROL   OF   MEN   DURING   REEDUCATION. 

The  question  whether  control  of  the  men  during  reeducation  should 
be  by  military  discipline  is  one  of  the  most  important  and  funda- 
mental problems  of  rehabilitation.  It  is  stated  in  reports  of  the 
interallied  conference  held  in  Paris  in  May,  1917,  that  the  training 
is  compulsory  and  under  military  discipline  in  France  and  Italy,1 

1  Training  in  Italy  is  required  for  six  months  only. 


62  TRAINING   OF   TEACHERS  FOE   OCCUPATIONAL  THERAPY. 

since  the  men  are  not  discharged  from  the  army  and  navy  till  their 
training  is  completed.  Frequent  references  are  found,  however,  to 
the  effect  that  the  men  have  to  be  persuaded  to  take  vocational  train- 
ing in  these  countries.  A  recent  visitor  .at  one  of  the  large  reedu- 
cation centers  near  Paris  states  that  the  men  are  induced  to  take 
training  by  being  allowed  to  stay  in  the  shops  where  their  friends  are 
working. 

Military  discipline  and  compulsory  training  seem  to  have  been 
only  partially  successful,  while  the  French  Minister  of  Education 
says: 

Very  many  disabled  soldiers  refuse  to  avail  themselves  of  the  facilities  of 
"  reeducation  professionnelle  "  *  *  *.  "There  is  probably  a  very  simple  expla- 
nation to  the  puzzle  of  these  conflicting  statements;  compulsory  "reeducation" 
may  be  perfectly  lawful  in  France,  but  may  never  or  hardly  ever  occur  *  *. 
In  any  case,  however,  compulsion  of  this  kind  is  rare  in  France,  if  it  occurs  at 
all,  and  is  recognized  as  generally  impracticable. 

Belgium  is  the  only  one  of  the  allied  nations  which  is  able  to  en- 
force training  during  convalescence,  due  to  the  fact  that  the  entire 
male  population  of  Belgium  is  mobilized  and  that  many  of  the  men, 
having  no  homes  to  return  to,  remain  as  patients  for  long  periods  of 
time.  The  French  Minister  of  Education  also  says: 

Still  more  instructive,  however,  is  the  evidence  as  to  the  great  Belgian  Insti- 
tute for  Disabled  Soldiers,  the  largest  and  most  remarkable  institution  of  its 
kind  that  has  ever  existed.  Here  there  is  no  doubt  at  all  as  to  the  propriety 
any  more  than  as  to  the  legality  of  compulsory  training,  but  it  is  found  to  be 
ineffective  as  training.  M.  Alleimm,  the  director  of  studies  there,  says :  "  Com- 
pulsion should  never  be  -employed.  In  certain  schools  80  per  cent  of  failures 
have  occurred  through  misapprehension  of  this  principle." 

Thus,  neither  Belgian  experience  nor  French  bears  out  the  idea,  which  not 
long  ago  had  some  currency,  that  the  compulsory  powers  of  army  discipline  can 
be  used  with  advantage  in  training  the  disabled  to  new  trades  or  professions. 

In  England  training  is  neither  compulsory  nor  under  military 
discipline.  In  Canada  the  problem  of  control  during  reeducation 
has  been  more  satisfactorily  worked  out  than  in  any  of  the  other 
countries.  The  men  are  under  military  discipline  as  long  as  they  are 
convalescing  in  the  hospitals  and  receiving  occupational  therapy  in 
the  curative  worpshops.  Upon  discharge  from  the  hospital  they  are 
given  their  pensions,  which  are  based  on  disability,  not  on  earning 
power  developed  in  the  workshop.  The  men  who  need  further  voca- 
tional training  come  under  the  control  of  the  vocational  branch  of 
the  military  hospitals  commission  command.  It  is  still  possible  to 
exert  authority  over  a  man  if  there  is  evidence  that  he  will  not  apply 
himself  to  his  work  or  if  it  appears  that  his  environment  and  habits 
are  such  that  the  effects  of  his  treatment  will  be  affected.  The  men 
are,  however,  placed  upon  their  own  responsibility  just  as  soon  as  it 
is  certain  that  their  health  and  future  will  not  be  jeopardized. 

Disabled  soldiers  and  sailors  are  men  who  have  been  accustomed 
to  military  discipline.  Military  life,  with  its  obedience  to  orders, 
has  a  tendency  to  prevent  individual  thinking  and  to  crush  natural 
initiative. 

He  shudders  at  the  idea  of  entering  tin  occupation  again  when  he  has  to 
continuously  apply  himself  for  hours  and  hours  every  day,  just  to  earn  n 
mediocre  living.  *  *  Military  life  is  exciting,  but  ordinarily  it  is  not 

really  as  hard  as  civilian  life,  except  for  a  few  supreme  hours  when  called  upon 
for  great  effort.1 

1  Dr.  F.  H.  Sexton,  address,  Rochester,  N.  Y.,  Nov.  15,  1917. 


TRAINING   OF   TEACHERS  FOE  OCCUPATIONAL   THERAPY.  63 

A  wounded  Canadian  officer,  discharged  from  a  hospital,  expressed 
his  surprise  at  finding  that  he  had  to  think  for  the  first  time  in  three 
years  when  and  where  and  what  to  eat.  The  return  to  civilian  life 
is  difficult  and  imposes  a  severe  mental  strain.  Yet  since  these  men 
must  enter  industry  as  civilians,  the  sooner  they  make  the  adjustment 
the  better.  T.  B.  Kidner,  vocational  secretary  of  the  military  hos- 
pitals commission,  has  said : 

I  feel  that  it  is  important  that  a  man  should  be  discharged  as  soon  as  he 
can  think  for  himself,  irrespective  of  the  fact  of  whether  or  not  his  vocational 
training  is  finished.  I  am  strongly  of  the  opinion  that  the  more  you  can  sur- 
round the  men  with  a  civil  atmosphere  the  better  it  is. 

Partly  for  this  reason  and  partly  because  the  schools  can  not  fur- 
nish complete  training  in  all  lines,  it  is  desirable  that  part  of  the 
vocational  training  be  taken  in  a  factory  under  real  working  condi- 
tions.1 

While  we  shall  continue  to  do  a  great  deal  of  reeducation  in  our  own  schools 
and  classes,  we  hope  to  arrange  that  all  reeducation  cases  shall  spend,  if  not 
the  whole,  at  least  the  final  period  of  training  in  some  commercial  industrial 
establishment,  under  actual  working  conditions,  punching  the  time  clock  regu- 
larly, and  in  other  ways  adjusting  themselves  once  more  to  reliance  on  them- 
selves and  regular  civilian  ways.2 

England  has  also  found  that  it  is  advisable  to  adjust  men  to  indus- 
trial demands  in  actual  shops  and  factories.  The  Dilution  of  Labour 
Bulletin,  issued  by  the  ministry  of  munitions  of  England,  states : 

It  must  be  remembered  that  a  man,  by  losing  a  limb,  does  not  necessarily 
acquire  a  fresh  habit  of  life.  Maimed  men  should,  therefore,  when  possible, 
always  pass  through  either  an  instructional  factory  or  similar  institution  or  a 
shop  in  which  for  a  few  weeks  they  can  be  sure  of  individual  attention  and 
tolerance,  in  order  that  they  may  acquire  or  reacquire  the  habits  of  shop 
discipline. 

Canada  has  found  that  it  is  not  difficult  to  maintain  control  of  the 
men  taking  vocational  education  without  military  discipline.  Eng- 
lish experience  is  much  the  same.  In  both  countries  the  men  receive 
allowances  during  training,  which  are  forfeited  on  failure  of  good 

1  In  France  the  men  were  given  an  allowance  to  live  at  home  and  take  instruction  in 
actual  factories  and  shops. 

"  Apparently  the  plan  did  not  work  well  for  several  reasons,  among  them  being  that 
no  guaranty  was  given  that  real  instruction  would  be  afforded  the  pupil ;  neither  was 
the  position  of  the  disabled  always  satisfactory  in  relation  to  the  unwounded  workman. 

"  Notwithstanding  this,  we  are  now  endeavoring  in  Canada  to  carry  out  a  plan 
whereby  partially  disabled  men  will  be  received  into  private  industrial  establishments 
for  vocational  reeducation. 

"  First,  only  limited  variety  of  occupations  can  be  taught  in  schools. 

"  Second,  that  in  a  very  few  cases  is  it  possible  to  give  training  in  school  workshop 
on  commercial  lines."  (T.  B.  Kidner,  address,  Boston,  Nov.  15,  1917.) 

When  a  man  is  apprenticed  in  Canada  the  Government  assumes  all  risk  and  expense. 
The  Government  pays  him  regular  salary,  the  employer  not  paying  him  anything  until 
he  becomes  of  use  to  the  employer.  When  he  does  become  of  use  the  employer  notifies 
the  vocational  officer  that  he  would  pay  the  man  a  certain  sum,  which  reduces  his  pay 
from  the  Government  just  that  much. 

This  arrangement  would  last  for  a  year  or  until  such  time  as  the  employer  found  the 
man  would  never  make  a  competent  worker.  In  such  event  the  vocational  officer  as- 
sumes charge  of  him.  The  result  is  : 

"  The  employer  takes  no  risk  ;  the  patient  is  constantly  learning.  It  costs  the  Gov- 
ernment no  more,  and  in  the  end  makes  a  useful  citizen  out  of  an  otherwise  worthless 
one.  It  is  strictly  an  economic  problem  so  far  as  the  employer  is  concerned,  involves 
no  financial  loss  on  his  part,  and,  if  entered  into  in  the  right  spirit  by  employers,  will 
reduce  the  taxes  for  pensions  enormously  in  the  end."  (F.  B.  Magbuson's  report  giveu 
before  the  Illinois  Council  of  National  Defense.) 

In  the  boot  and  shoe  repairing  as  well  as  in  the  hand-sewn  boot  aud  shoe  making 
trades  the  British  minister  of  pensions  authorizes  the  payment  of  fees  of  5s.  and  7s.  6d., 
respectively,  per  week  to  the  employer  for  the  first  six  mouths  of  a  man's  apprentice- 
ment. 

2T.  B.  Kidner's  address,  Boston,  Mass.,  Nov.  15,  1917, 


64  TEAINIXG   OF   TEACHERS  FOR   OCCUPATIONAL   THERAPY. 

conduct.  Of  the  actual  working  of  the  system  in  Canada.  Mr.  Kidner 
says : 

If  a  man  absents  himself  from  classes  without  cause,  or  lie  leaves  the  class, 
the  district  vocational  officer  warns  the  man  that  he  may  be  liable,  and  that 
his  course  may  be  liable  to  be  canceled.  That  is  all  the  hold  we  want. 

The  control  of  the  men  during  reeducation  in  Canada  resolves  into : 
First,  control  by  military  authority  during  convalescence  and  before 
hospital  discharge;  and,  second,  contr/ol  decided  in  individual  cases 
by  the  vocational  branch  after  hospital  discharge  and  during  voca- 
tional education.  It  is  recognized  that  the  period  of  adjustment  after 
hospital  discharge  is  particularly  perilous,  and  every  effort  is  made 
during  the  period  of  vocational  education  to  help  the  patient  accom- 
modate himself  to  the  demands  of  civilian  life.  It  is  absolutely  neces- 
sary that  the  amount  of  the  pension  be  determined  after  hospital 
discharge,  so  that  the  men  may  enter  on  their  vocational  work  know- 
ing that  no  reduction  will  be  possible  and  that  any  earning  capacity 
they  acquire  will  be  in  addition  to  their  pension. 

Inasmuch  as  the  peri/od  of  adjustment  to  civilian  life  is  difficult, 
and  since  only  about  20  per  cent  of  the  men  have  the  opportunity  to 
adjust  themselves  during  the  period  of  vocational  education,  it  is 
evident  that  some  kind  iof  preparation  for  civilian  life  must  be 
offered  to  the  80  per  cent  who  will  be  able  to  return  to  their  former 
work  after  convalescence  without  further  training.  The  curative 
workshop,  like  the  other  departments  of  the  hospital,  must  be  under 
military  discipline.  Authority  is  necessary  during  convalescence  so 
that  the  men  shall  not  retard  or  even  permanently  prevent  their  re- 
covery by  excessive  exercise  or  rest,  wrong  food,  or  bad  habits.  The 
"work  prescription"  must  be  enforced  just  as  rigidly  as  any  other 
kind  of  prescription.  Beyond  this  point,  and  except  in  rare  in- 
stances, there  should  be  no  recourse  to  military  discipline. 

The  greatest  benefit  derived  by  the  men  is  the  hardening  of  mind  and  muscle 
in  preparation  for  civilian  life.  For  many  months  they  have  not  been  compelled 
to  think  for  themselves,  nor  have  they  been  forced  to  think  of  their  own  food 
or  raiment  or  the  welfare  of  their  families.  For  the  greater  part  of  the  time 
the  daily  effort  required  in  military  life  has  not  been  as  great  as  they  formerly 
made  in  earning  a  living.  After  the  pain  and  suffering  of  their  wounds  are 
allayed  they  spend  many  wreeks  in  hospitals  and  convalescent  homes  in  a  state 
of  pampered  and  glorified  idleness.  The  classes  fill  in  the  gaps  between  the 
other  items  of  routine,  such  as  massage,  physical  training,  etc.,  and  produce  a 
well-ordered  and  well-rounded  day,  much  like  the  civilian  life  which  they  are 
rapidly  approaching.1 

In  order  that  the  men  may  as  far  as  possible  be  surrounded  by 
civilian  atmosphere,  the  instructors  should  not  be  in  uniform.  The 
men — 

regard  the  uniform  as  a  badge  of  military  honor,  to  be  won  in  actual  battle 
experience,  and  although  they  have  entire  respect  for  a  civilian  expert  in  some 
particular  line  they  would  not  have  the  same  respect  for  the  same  civilian  if 
they  considered  him  masquerading  as  a  military  officer  when  not  actually  a 
military  man.  If  expert  civilians  are  to  be  used  for  this  purpose,  there  is  still 
another  reason  against  commissioning  them  and  putting  them  in  uniform.  This 
consists  in  the  natural  breach  between  the  officer  and  the  private.2 

In  Canada  there  are  instances  of  men  taken  out  of  the  military 
service  to  teach  as  civilians.  One  of  the  most  important  features 

1  Military  Hospitals  Commission  of  Canada  Report.  May,  1917. 

2  Douglas  C.  McMurtrio,  in  the  Survey,  Nov.  3,  1917. 


TRAINING   OF    TEACHERS   FOR    OCCUPATIONAL   THERAPY.  65 

for  the  success  of  occupational  therapy  is  the  personal  relationship 
of  teacher  to  pupil.  Rank  is  an  invisible  barrier  and  prevents  a  pri- 
vate from  giving  to  an  officer  the  intimate  details  of  his  life  which 
may  be  important  to  the  determination  of  his  future  career.  When 
the  officer  or  instructor  is  in  civilian  clothes,  however,  when  he  ad- 
dresses the  patient  as  Mr. ,  or  calls  him  by  his  first  name,  and 

treats  him  as  an  equal,  he  inspires  both  friendship  and  confidence, 
and  the  success  of  rehabilitation  in  many  cases  depends  upon  just 
such  contacts. 

So  the  vocational  officers  establish  over  the  men  an  influence  more  effective 
than  cold  and  formal  discipline.  It  is  established  by  painstaking  and  indi- 
vidual attention,  tact,  an  understanding  sympathy,  and  personal  force.  Its 
establishment  is  costly  in  that  the  number  of  soldiers  under  such  "discipline" 
by  a  given  man  is  limited,  and  in  that  the  strength  of  character  and  general 
raliber  of  the  vocational  official  must  be  well  above  the  average.  Lacking  in 
these  qualifications,  the  adviser  must  be  a  failure  in  his  job,  and  the  quicker 
he  is  weeded  out  the  better  for  his  pupil  veterans.1 

The  work  during  convalescence  must  be  so  interesting  and  instruc- 
tive that  not  only  will  discipline  be  unnecessary,  but  that  the  men 
who  will  need  further  training  after  discharge  will  be  willing  and 
eager  to  undertake  it.  An  unwilling  pupil  is  unresponsive,  and,  in 
addition,  a  poor  investment.  Military  discipline  must  be  wisely 
and  sparingly  used  lest  it  defeat  the  very  purpose  for  which  it  is 
intended  by  forcing  the  men  to  work  and  prejudicing  them  against 
further  training  or  civilian  employment  upon  discharge. 

The  processes  of  adjustment  involve  a  nervous  reeducation  in 
which  occupation  proves  a  more  effective  agent  than  either  medicine 
or  discipline. 

Disciplinary  troubles  which  are  always  present  when  a  body  of  men  have 
time  hanging  heavily  on  their  hands  disappear  almost  entirely  when  vocational 
classes  are  established.  *  *  As  a  pioneer  in  the  field  of  occupational 

Therapy  on  this  continent  has  well  put  it,  "  a  better  job,  or  a  job  done  better," 
is  the  motto  for  the  self-improvement  classes  provided  during  convalescence.3 

Civilian  occupation  is  the  best  instrument  for  breaking  down  mili- 
tary habits  and  reestablishing  initiative  and  continuous  effort.  Work 
properly  conducted  is  the  best  form  of  self-discipline,  as  it  should 
teach  the  patient  to  think  for  himself,  develop  his  latent  resources, 
inspire  ambition,  and,  above  all.  create  regular  habits  of  industry 
and  thought.  Such  habits  must  be  self-imposed;  they  can  not  be 
commanded. 

PERMANENT    PROVISION    FOR    DISABLED    MEN. 

Permanent  provision  must  be  made  for  the  medical  treatment, 
vocational  training,  placement,  and  follow  work  for  the  disabled 
men. 

Disabled  men  frequently  become  ill  and  have  a  recurrence  of  their 
disability.  Such  men  must  be  allo\ved  to  reenlist  for  the  period  of 
their  illness  so  that  they  may  not  run  the  risk  of  being  in  some 
charitable  institution  with  themselves  and  dependents  unprovided 
for.  Any  man  who  has  been  disabled  in  his  country's  service  should 
l)e  entitled  for  the  rest  of  his  life  to  whatever  medical  care  he  may 

1  Douglas   C.   McMurtrio.   in   the   Survey.   Nov.   .°,.    1017. 

2  J.  L.  Todd  and  T.  B.  Kidner.     The  Retraining  of  Disabled  Men. 

42298°— 8.  Doc.  1G7.  65-2 5 


66  TBAINING   OF   TEACHERS  FOE   OCCUPATIONAL   THERAPY. 

need  in  a  military  hospital.  Such  care  should  be  followed  when 
necessary  by  occupational  therapy  and  upon  recovery  "lie  should  again 
have  assistance  in  securing  employment.  Meanwhile  his  dependents 
should  receive  an  allowance.  Such  provision  will  prevent  an 
enormous  increase  in  charity  in  the  years  following  the  war  and 
prevent  as  well  the  once  rehabilitated  man  from  falling  into  the 
pitiful  ranks  of  the  handicapped  after  a  period  of  illness.  Follow 
work  with  a  confidential  guide  of  all  disabled  men  is  necessary  to 
insure  the  permanency  of  rehabilitation  and  to  prevent  any  duplica- 
tion of  effort  in  their  behalf.  France  maintains  a  follow  system 
through  the  national  office.  Canada  is  establishing  a  follow  system 
for  her  reeducation  cases. 

The  machinery  built  up  to  deal  with  war  invalids  will  be  valuable 
in  conserving  the  health  of  the  civil  population  after  the  war.  Of 
the  tuberculosis  situation  in  Canada  the  military  hospitals  commis- 
sion report  of  May,  1917,  states  that — 

The  problem  handled  by  the  commission  is  largely  a  civilian  one,  and  the 
result  of  the  work  \vhich  has  been  done  should  have  a  marked  influence  ou  the 
future. 

DEMOBILIZATION, 

The  problem  of  demobilization  is  a  complicated  one.  Every  re- 
turned man  placed  and  absorbed  in  industry  lessens  the  difficulty, 
says  Mr.  Kidner. 

It  will  be  found  that  in  many  instances  any  special  machinery  devised  for 
dealing  with  the  problems  of  disabled  men  can  usefully  be  employed  in  meeting 
the  problems  of  demobilization  and  employment  after  the  war.1 

VALIK    OF    CIVILIAN    STHKNT.TH    AM)    VITALITY. 

The  powtr  of  a  nation  lies  in  its  civilian  strength  and  vitality. 
The  purpose  of  the  rehabilitation  of  the  disabled  is  to  prevent  the 
drain  of  dependency  aud  to  increase  economic  usefulness.  There  are 
two  classes  of  men  not  included  in  the  disabled  from  the  front  whose 
economic  usefulness  is  quite  as  vital  to  the  welfare  of  the  country 
as  is  that  of  the  disabled  soldier.  They  are,  first,  the  men  returned 
from  the  front  as  undesirable  but  not  disabled,  and,  second,  those 
unfit  for  efficient  citizenship  as  well  as  military  service. 

(a)  Rehabilitation  of  the  " undesirable" — A  group  of  men  so  un- 
desirable that  they  have  been  dismissed  from  the  Army  are  hardly 
more  desirable  in  a  civilian  community  and  their  absorption  into 
society  is  attended  with  serious  dangers.     That  physical  conditions 
are  frequently  the  cause  of  misconduct  and  inefficiency  has  long  been 
known.    If  these  men  can  be  put  through  a  vigorous  medical  exami- 
nation on  their  return,  all  possible  abnormal  conditions  corrected, 
occupational  therapy-    and  vocational  training  given   as  necessary, 
these  men,  like  the  disabled  soldiers,  might  be  made  serviceable. 

The  ministry  of  pensions  in  England  has  agreed  that  institutional 
treatment  might  be  extended  to  men  discharged  for  causes  not  at- 
tributable to  war  service.2 

( b )  Rehabilitation  of  the  "  unfit." — The  conditions  revealed  by  the 
medical  examining  boards  for  enlisted  men  show  that  four  out  of 

1  J.  L,  Todd  and  T.  B.  Kidner.     The  Retraining  of  Disabled  Men. 

2  War  Pensions  Gazette,  July,   1917. 


TRAINING    OF    TEACHERS   FOR   OCCUPATIONAL   THERAPY.  67 

every  five  men  who  volunteered  during  1D15  and  1916,  and  were 
rejected,  were  refused  for  causes  trivial  and  absolutely  remedial  in 
the  great  majority  of  cases.1  A  plan  has  been  proposed*  for  the  recla- 
mation of  these  men. 

A  full  realization  of  the  meaning  of  man  power  and  the  tremendous  wastage 
which  is  taking  place  in  our  Army  is  the  thing  that  prompted  the  reclamation 
plan.2 

When  reclamation  of  these  men  involves  prolonged  medical  or 
surgical  care,  occupational  therapy  followed  by  vocational  training 
will  enable  many  of  these  men  not  only  to  go  to  the  front  but  to  go 
with  the  training  of  skilled  mechanics  and  technicians.  The  men 
not  able  to  go  to  the  front  will  be  equally  benefited  to  serve  back  of 
the  lines. 

Tt  is  already  evident,  however,  that  many  other  men  would  be  glad  to  under- 
take vocational  training  and  it  is  also  clear  from  the  records  of  the  industrial 
history  of  the  large  majority  of  the  candidates  for  reeducation  that  there  is 
in  Canada  a  great  national  need  for  vocational  and  industrial  training  in  the 
country  at  large,  apart  altogether  from  the  particular  aspects  of  the  question 
as  applied  to  disabled  soldiers.3 

Canada  estimates  that  every  man  who  was  broken  down  in  train- 
ing cost  $2,000.  At  an  estimate  of  the  cost  of  $50  to  reclaim  a  man, 
a  hundred  million  dollars  will  reclaim  2,000,000  men,  and  thus  H.  P. 
Davidson,  of  the  Red  Cross,  has  pointed  out  that  our  national  wealth 
will  have  been  increased  $30,000,000,000.4 

(c)  Rehabilitation  of  the  industrially  handicapped. — The  indus- 
trially crippled  and  handicapped  form  a  group  at  all  times  in  need 
of  rehabilitation.  Kraus,5  of  Germany,  'claims  that  only  41  out  of 
100  accidental  injuries  could  be  accounted  for  after  six  years,  showing 
complete  readaptation  on  an  improved  economic  condition.  There 
are  handicapped  men  who  have  been  properly  trained  during  con- 
valescence and  who  look  upon  their  vocational  training  as  their 
greatest  opportunity.  Employers  have  found  such  men  most  valu- 
able, as  they  realize  the  difficulty  of  securing  another  position  and 
in  their  desire  to  compete  they  often  surpass  the  work  of  a  normal 
man.  As  Prof.  Amar  has  noted — 

The  mutile  possesses  always  a  perfectly  utilizable  capacity  for  some  kind  of 
work.  *  *  *  He  may  actually  compensate  for  his  physical  deficit  by  an 
active  good  will,  which  increases  his  social  value.  This  is  a  psychologic  fact 
which  must  be  turned  to  advantage.6 

NECESSITY  FOR  OCCUPATIONAL  THERAPY  AT  ALL  TIMES. 

Occupational  therapy  as  a  war  measure  must  not  be  allowed  to  dis- 
tort the  present  and  future  needs  of  occupational  therapy  out  of  their 
true  proportion. 

It  is  estimated  by  the  Canadian  authorities  over-seas,  based  upon 
the  experience  of  last  year,  that  the  numbers  of  men  returning  dur- 
ing the  ensuing  year  will  be  at  the.  rate  of  1.200  to  1.500  men  a  month, 
or.  from  12,400  to  18,000  men  for  the  year.  In  all  probability  the 

1  The  Surgeon  General's  Report  for  the  fiscal  year  ending  June  30,  191G,  in  "  Reclama- 
tion of  the  Rejected  Candidate  for  the  Army."     Modern   Hospital,   December,   1917. 

2  Dr.  J.  H.  Guayle.     Modern  Hospital,  December,   1917. 

3  J.  L.  Todd  and  T.  B.  Kleiner.     The  Retraining  of  Disabled  Men. 

4  Modern  Hospital,  December,  1917. 

5  Journal   American   Medical   Association,   Mar.    31,   1915. 

6  Scientific  American  Supplement,  Nov.  25,  1916. 


68  TRAINING    OF    TEACHERS   FOR   OCCUPATIONAL   THERAPY. 

number  of  disabled  Americans  will  not  only  not  exceed  that  of  Can- 
ada for  the  first  year  at  least,  but  be  far  less.  In  1913  the  number 
of  industrial  accidents  involving  more  than  four  weeks'  disability 
was  700,000.  Industrial  accidents  have  increased  since  1913.  On 
the  basis  of  the  conservative  estimate  of  1913,  however,  there  are  over 
thirty-eight  times  as  many  industrial  accidents  in  a  year  in  the 
United  States  as  the  maximum  number  of  men  expected  to  return 
to  Canada  in  the  next  year. 

The  disabilities  of  industrial  accidents  have  many  points  in  com- 
mon with  the  disabilities  of  war,  and  if  occupational  therapy  is  a 
war  measure  necessary  for  the  returned  soldier  and  sailor,  it  would 
seem  to  be  just  as  urgent  for  the- victims  of  civil  disabilities,  who 
outnumber  the  military  victims  by  a  conservative  estimate  of  thirty- 
eight  times.  In  1910  there  were  60,769  inmates  in  insane  asylums. 
Except  for  a  few  splendidly  conducted  institutions,  chiefly  in  Massa- 
chusetts, the  practice  of  occupational  therapy  among  the  insane  is 
far  from  ideal,  yet  the  insane  in  the  United  States  in  1910  were 
three  times  as  numerous  as  the  maximum  number  of  men  expected  to 
return  to  Canada  during  the  next  year.  In  the  same  year  1,953,000 
patients  were  treated  in  public  and  philanthropic  hospitals  in  the 
United  States  and  2,440,000  treated  in  free  dispensaries,  a  total  of 
4,393,000.  One  per  cent  of  this  number,  or  43,930  patients,  is  double 
the  number  of  disabled  men  returned  that  Canada  will  receive  on  her 
maximum  estimate. 

The  war  emergency  and  the  widespread  public  interest  in  war 
cripples  makes  the  present  an  opportune  moment  for  the  serious 
study  of  the  possibilities  of  occupational  therapy,  and  the  standardi- 
zation of  teacher  training  in  this  field.  Such  a  study  will  build  a 
permanent  structure  which  may  provide  for  better  convalescence  and 
better  vocational  opportunities  for  all  the  handicapped.  It  was 
stated  in  the  minutes  of  the  first  two  meetings  of  the  committee  for 
reeducation  of  war  cripples  held  in  Paris  in  Juty,  1917,  that — 

the  institutions  would  not  cease  to  exist  with  the  conclusion  of  peace,  but  would 
then  take  up  all  questions  relating  to  victims  of  accidents  at  work. 

Prof.  Jules  Amar  has  said: 

The  war  will  be  over,  but  the  industrial  work  and  the  necessity  for  Hie 
scientific  study  and  physical  organization  of  it  will  be  with  us  forever. 

There  will  always  be  the  need  for  rehabilitation  of  the  damaged 
human  material  discarded  from  the  industrial  world. 

The  economic  and  social  problems  which  are  crystalizing  in  the 
present  emergency,  as  T.  B.  Kidner  has  pointed  out — 

are  only  made  more  apparent  through  their  being  forcibly  brought  to  our  atten- 
tion by  the  urgency  of  the  disabled  soldier  problem  if,  for  instance,  any  doubts 
exist  as  to  the  necessity  for  a  broad  and  generous  scheme  of  industrial  train- 
ing for  the  nation,  the  contrast  in  the  outlook  for  the  future  between  the  disabled 
men  who  have  been  trained  thoroughly  in  technical  lines  before  enlistment 
and  those  whose  only  commodity  was  unskilled  labor  should  remove  them. 
On  the  one  hand  confidence  and  calm  serenity,  on  the  other,  fear  and  dread  of 
the  future.  We  are  already  hearing  of  preparedness  for  the  "  war  after  the 
war." 

Occupational  therapy  touches  all  those  vital  problems  and  must 
be  utilized  in  the  future,  not  only  in  healing  and  alleviating  more 
extensively  those  whom  it  now  touches,  but  in  reaching  all  classes. 
For  those  in  need  of  economic  adjustment  and  training,  occupational 
therapy  may  afford  in  convalescence  the  one  great  opportunity. 


TRAINING    OF    TEACHERS  FOR   OCCUPATIONAL   THERAPY.  69 

VALUE    OF   THE    HANDICAPPED. 

If  the  war  should  finally  end  in  economic  exhaustion,  that  nation 
may  ultimately  triumph  which  is  best  able  to  use  over  again  her 
men.  It  is  claimed  that  Germany  uses  85  to  90  per  cent  of  her  dis- 
abled back  of  the  lines,  and  that  the  majority  of  the  remaining  10 
to  15  per  cent  are  entirely  self-supporting.  Belgium,  whose  deple- 
tion has  been  the  greatest,  was  the  first  nation  successfully  to  use 
over  again  her  men.  Not  only  has  the  large  Belgian  reeducation 
center  of  Port  Villez  been  self-supporting,  but  in  addition  it  has 
paid  back  to  the  Belgian  Government  the  entire  capital  cost  of  in- 
stallation. The  men  in  the  meantime  have  not  only  received  43 
centimes  per  day,  the  regular  pay  of  the  Belgian  soldier,  but  also  5 
to  20  centimes  per  hour  according  to  their  work.  In  addition,  sur- 
plus profits  are  funded  for  the  men.  Belgium  before  the  war  was 
one  of  the  most  highly  trained  countries  in  Europe.  Forty-three 
trades  are  taught  at  Port  Villez  under  the  most  competent  instruc- 
tors. A  large  part  of  the  output,  material,  equipment,  and  tools 
made  are  for  the  Belgian  Army.1 

Economic  necessity  has  made  possible  the  results  achieved  in  Bel- 
gium. For  the  other  nations  not  so  hard  pressed  the  rehabilitation 
of  the  disabled  and  the  strengthening  of  the  vitality  of  the  civil  popu- 
lation may  be  an  important  and  perhaps  a  determining  point  in  their 
economic  future. 

If  this  problem  is  handled  with  good  ordinary  business  judgment,  if  the 
soldier  is  treated  in  a  straightforward  manly  fashion,  without  sentimentality  or 
patriotic  hysteria,  he  will  find  that  his  disability  will  turn  out  to  be  really  a 
staff  instead  of  a  millstone.2 

To  what  extent  this  Nation  will  be  forced  to  use  over  again  her  men 
can  not  be  determined.  It  is  certain,  however,  that  our  economic 
future  depends  to  a  large  extent  upon  the  rehabilitation  of  those  dis- 
abled both  in  w^ar  and  industry.  The  services  of  the  men  disabled 
at  the  front  are  needed  back  of  the  lines  and  in  the  great  task  of  re- 
construction after  the  war.  The  channels  of  immigration  are  closed, 
and  the  drain  on  our  own  labor  market  is  tremendous.  The  time  has 
passed  when  the  supply  of  skilled  labor  was  as  inexhaustible  as  our 
natural  resources  were  thought  to  be.  We  can  no  longer  afford  to 
continue  our  former  wasteful  methods  and  we  must  conserve  every 
vestige  of  labor  as  an  economic  asset. 

LETTERS  FROM  REHABILITATED  SOLDIERS. 

Some  of  the  men  have  voluntarily  written  letters  to  their  old  teach- 
ers, some  of  which  testify  to  very  considerable  improvement  in  the 
man's  wage-earning  powyer.  In  giving  the  following  details  of  the 
cases  of  a  few  soldiers  the  names  are  not  mentioned  for  personal 
reasons.3 

"As  you  know,  for  the  past  four  weeks  I  have  been  at  work  in  the  tool  room 
of  the  Dominion  Bridge  Co.,  and  I  just  thought  I  would  like  to  drop  you  a 
line  to  express  my  thanks  to  the  military  hospitals  commission. 

1  Fuse  boxes  which  cost  30  francs  apiece  mamifactured  in  the  United  States  are  made 
by  Belgian  cripples  for  10  francs  apiece,  and  give  a  prolit  of  2S   francs,  or  25  per  cent, 
to  the  establishment. 

2  Dr.  F.  H.  Sexton,  address,  Rochester,  N.  Y.,  jSfov.  15,  1917. 

2  Military   Hospitals   Commission   Keport,   May,   1U17.  I 


70  TKAIKING   OF   TEACHERS  FOE  OCCUPATIONAL   THERAPY. 

"  When  I  came  back  from  the  front  in  October,  1916,  I  was  not  able  to  read 
or  write  *  *  *. 

"  When  the  M.  H.  C.  opened  the  machine  shop  at  McGill  I  decided  to  take 
up  the  course,  as  I  wanted  to  get  a  trade  for  myself.  I  had  never  worked  on 
machines  before,  so  I  had  a  lot  to  learn,  but  I  stuck  with  it,  and  when  I 
got  my  discharge  three  months  later  I  was  able  to  secure  my  job  with  the 
Dominion  Bridge  Co.  I  received  $21.10  per  week  since  I  started.  The  fore- 
man told  me  this  week  that  he  was  going  to  put  me  on  a  new  machine  and 
this  would  mean  more  money  for  me.  I  expect  to  get  about  $30  per  week. 

"  If  it  had  not  been  for  the  school  I  never  would  have  been  in  the  place  I 
am  to-day.  Before  the  war,  I  was  driving  a  team  at  $15  per  week.  I  had  also 
worked  on  a  pile  driver  at  $18  per  week,  so  you  see  I  am  now  able  to  earii 
almost  twice  as  much  as  I  could  before.  I  hope  all  the  returned  boys  will 
see  the  chances  they  have  in  the  school  and  make  the  most  of  them." 

No.  61013,  Pvt. .  Twenty-second  Battalion: 

"  I  was  discharged  yesterday.  So,  to  my  regret,  I  will  no  longer  be  able  to 
attend  your  class. 

"But,  on  the  occasion,  I  wish  to  express  my  satisfaction  for  the  good  and 
practical  instruction  I  secured  from  you,  in  connection  with  my  trade,  through- 
out my  convalescent  period. 

"  Before  I  enlisted  I  was  an  ordinary  machinist,  and  I  often  realized  then 
that  I  was  lacking  of  some  technical  information,  especially  such  as  is  related 
with  shop  sketching  and  the  reading  of  blue  prints. 

"Now,  I  feel  that  I  can  go  back  to  work  with  pride,  because  I  have  learned, 
through  your  instruction,  to  understand  better  the  importance  and  advantages 
of  my  trade,  and  because  I  am  assured  that  now  I  can  work  myself  up  rapidly 
and  command  better  salaries  and  position. 

"  You  have,  Mr. .  set  me  on  this  path  and  I  wish  to  thank  you  heartily 

for  it. 

"  Yours  respectfully  and  obliged,  and  will  you  please  send  me  a  letter  of 
recommendation  of  some  kind  ;  1  will  appreciate  it." 

The  following  letter  was  written  by  a  man  who  was  an  excellent 
machinist,  but  had  never  been  able  to  read  drawings  with  any  facility. 
After  two  and  a  half  months'  instruction  in  mechanical  drawing,  in 
which  the  man  showed  an  extraordinary  ability,  he  was  discharged. 
He  immediately  stepped  into  a  position  as  a  foreman,  because  of  his 
new  knowledge,  at  a  very  satisfactory  salary. 

No.  51340,  Pvt.  .  P.  P.  C.  L.  I.: 

"Despite  my  30  years  of  experience  as  a  mechanic,  I  can  state  that,  through 
your  instruction  and  assistance,  my  efficiency  and  earning  power  were  consider- 
ably increased. 

"  The  fact  is,  that  at  the  outbreak  of  the  war,  when  I  enlisted,  I  was  earning 
about  $3  a  day  at  my  trade.  At  present,  since  I  am  discharged  from  military 
service,  I  am,  technically,  a  better  man  all  around;  I  am  able  now  to  hold  a 
job  as  foreman  in  a  machine  shop,  with  more  than  twice  the  salary  I  was 
getting  before." 

No.  24933,  Pvt.  ,  Thirteenth  Battalion: 

"  This  is  to  certify  that  prior  to  my  enlistment  for  over-seas  service  I  was 
employed  with  the  Duncan  Milk  Co.,  of  this  city,  receiving  $12  per  week  MS 
driver.  I  spent  nine  years  on  a  farm.  I  always  had  a  liking  for  drawing  and 
felt  that  if  ever  I  had  the  chance  I  would  take  up  a  course  in  mechanical 
drawing.  This  opportunity  was  offered  me  at  the  Grey  Nuns'  Convalescent 
Home,  Montreal,  where,  after  six  weeks'  constant  application  to  the  work,  I 
am  in  a  position  to  accept  an  appointment  with  the  pensions  board  at  Ottawa, 
with  an  initial  salary  of  $75  per  month." 

Pvt.  W.  Rollerson,  previously  a  stenographer,  earning  $70  a  month ;  took 
a  course  of  stenography  and  bookkeeping  at  Convalescent  Hospital,  Deer  Lodge, 
and  is  now  earning  $1,000  a  year.  Employed  in  the  customhouse. 

i 


TRAIXI^'G   OF    TEACHERS  FOR   OCCUPATIONAL   THERAPY.  71 

Pvt.  J.  Bicknell  was  a  polisher  earning  £<>0  a  month.  Took  five  months' 
course  of  commercial  work  and  is  now  earning  ,$87.50  as  bookkeeper  in  the 
ordnance  department. 

Pvt.  J.  E.  Billett  was  a  general  laborer  previous  to  enlistment,  earning  a 
variable  wage.  He  took  a  six  months'  course  in  woodwooking  room  at  Deer 
Lodge  and  is  now  earning  an  average  wage  of  $70  a  mouth  as  a  wood  carver 
at  the  Alaska  Bedding-  Co. 

Pvt.  Wilkie  was  a  blacksmith's  helper  before  enlistment.  He  took  a  short 
course  in  the  blacksrnithing  and  oxyacetylene-wekling  class  at  the  Kelvin 
School  and  is  now  employed  by  the  Winnipeg  school  board  as  a  blacksmith  and 
oxyacetylene  welder,  at  a  salary  of  $90  a  month. 

No.  22921,  Sergt. ,  Twelfth  Battalion : 

"  It  is  indeed  gratifying  for  us  (returned  soldiers)  to  know  that  there  is  such 
a  place  as  the  vocational-training  school,  to  which  we  can  go  on  our  return 
to  Canada. 

"  I  had  the  pleasure  of  being  there  for  two  months,  studying  shorthand  and 
typewriting,  and  then,  through  your  recommendation,  I  was  able  to  get  a  very 
good  position  as  visitor  in  the  Montreal  district  ottice  of  the  board  of  pension 
commissioners  for  Canada." 

The  following  letters  express  the  points  of  A'iew  of  three  grateful 
Englishmen  and  one  Irishman.1 

DEAR  BOYS  :  I  joined  up  on  August  30,  1914,  in  the  Royal  Engineers  and  was 
wounded  at  Loos  by  a  ritle  bullet  in  the  head,  leaving  my  right  arm  paralyzed 
and  at  times  severe  pains  in  the  liead.  I  must  say  this  made  me  very  despond- 
ent and  downhearted,  and  I  did  not  look  forward  very  hopefully  to  the  future 
on  my  discharge  from  hospital.  I  believe  I  was  one  of  the  first  boys  to  start  a 
course  of  training  for  disabled  soldiers.  I  must  say  that  the  careful  instruc- 
tion which  we  boys  received  greatly  bucked  and  encouraged  us  for  the  future. 
1  started  work  for  the  New  System  Telephone  Co.  under  the  chief  engineer,  who 
lias  greatly  interested  himself  in  me  and  other  wounded  soldiers  to  be  tele- 
phone engineers.  The  work  is  of  an  interesting  nature.  I  was  a  butcher  before 
joining  up,  but  having  trained  on  for  this  new  work  I  can  now  look  forward  to 
the  future  with  a  light  and  glad  heart.  I  can  only  say  to  all  the  boys  who  may 
read  this  don't  be  downhearted.  I  was  once,  but  not  now.  So  cheer  up,  boys. 
Believe  me,  yours,  sincerely, 

A.  CLAY. 

SIK  :  I  left  school  at  the  age  of  14  and  then  worked  at  a  cement  factory  as  a 
laborer.  After  serving  six  years  and  reaching  the  position  of  a  leading  cook  I 
was  blown  up  in  the  North  Sea  by  the  enemy  on  board  H.  M.  S.  Lightning,  a 
destroyer,  in  which  I  was  dangerously  wounded  and  lost  my  right  leg.  I  used 
to  worry  when  I  thought  how  I  could  earn  my  living  the  rest  of  my  life,  but 
after  I  heard  there  was  a  chance  to  learn  a  trade  I  cheered  myself  up  and  went 
in  for  handsewn  bootniaking.  I  am  sure  there  are  good  prospects  in  life  once  it 
is  learned. 

I  have  now  finished  my  training  of  a  year  and  am  going  into  a  job  in  the 
West  End  of  London.  I  have  been  trained  free  at  the  Cordwaiuers'  Technical 
College,  where  we  had  good  teachers  and  are  well  cared  for.  I  was  pleased 
when  I  got  my  first  9s.  9d.  for  the  pair  of  ladies'  shoes  I  made.  I  can  make  all 
sorts,  so  I  shall  be  able  to  take  work  all  the  year  around. 
Yours,  respectfully, 

CHARLES  W.  WOODING. 

We  went  out  to  the  Mediterranean  and  then  to  Gallipoli,  where  I  was  badly 
wounded  and  lost  my  right  leg  (very  high  amputation).  My  previous  occupa- 
tion having  been  that  of  a  gardener,  I  began  to  wonder  what  I  should  do.  I 
then  joined  a  special  course  of  electrical  work  whilst  in  hospital  and  went  to  a 
training  center  after  leaving  and  got  on  so  well  that  I  got  a  good  job  at  the 
C.  A.  V.  Magneto  Works,  where  I  am  doing  very  well;  the  work  I  have  to  do 
suits  me,  as  I  can  sit  down  at  it.  I  would  advise  everyone  who  can  not  go  back 

1  Recalled  to  Life,  No.  1. 


72  TRAINING   OF   TEACHERS  FOR   OCCUPATIONAL  THERAPY. 

to  their  old  jobs  to  learn  a  trade.    I  am  earning  more  now  than  I  did  before  I 
joiiied  up,  apart  altogether  from  my  pension. 

CH.  E.  JANKS. 

I  was  in  the  merchant  service  before  the  war,  but  joining  the  Irish  Guards 
March,  1915,  went  out  to  France,  took  part  in  the  fighting  at  Loos,  and  was 
wounded  at  Ypres.  I  got  a  shell  wound  in  the  shoulder  which  has  rendered  my 
right  arm  nearly  useless.  I  took  advantage  of  the  offer  of  being  trained  as  an 
electrician  storekeeper,  and  after  three  months'  training  have  obtained  a  good 
situation,  and  the  work  is  quite  easy  for  me  notwithstanding  my  disablement, 
which  prevented  me  following  my  former  occupation. 

F.  POWER, 
Lute  Irish  Guard 8. 

SUGGESTED   REGISTRATION    AND   RECORD  "BLANKS    FOR    CHARTING    PROGRESS 

OF  PATIENTS. 

The  following  blanks  are  suggested  for  charting  the  necessary  data 
of  each  patient  from  his  entrance  in  the  hospital  until  his  discharge 
and  placement  in  industry,  vocational  school,  or  institution. 

Hospital  registration,  Form  1,  provides  the  patient's  name,  rank, 
and  home  address.  It  shows  the  handicap  with  which  he  enters  the 
hospital,  his  previous  education  and  training,  his  former  occupation, 
income,  and  the  possible  future  occupation  he  will  be  able  to  follow, 
with  suggestions  for  vocational  training  or  improvement.  The  social 
information  will  be  of  value  in  placing  the  men,  and  the  opportunity 
for  communicating  with  persons  interested  in  the  patient's  welfare  is 
provided. 

The  curative  shop  weekly  record,  Form  2,  indicates  the  patient's 
changing  physical  and  mental  conditions,  with  physician's  instruc- 
tions and  recommendations  of  the  vocational  expert.  The  observa- 
tions of  the  instructor,  which  show  the  patient's  methods  of  work,  the 
quantity  and  quality  of  his  output,  will  be  of  value  in  placing. 

Hospital  discharge,  Form  3,  is  printed  on  the  reverse  of  Form  1, 
hospital  registration,  which  has  already  recorded  such  social  history 
of  the  man  as  is  desirable.  Provision  is  made  on  Form  3  for  showing 
changes  in  handicap,  education,  and  vocational  training  since  conva- 
lescence in  the  curative  workshop.  The  patient's  placement,  whether 
in  industry,  vocational  school,  or  institution,  is  recorded,  as  well  as" 
the  persons  communicated  with  and  responsible  for  his  follow  work. 

The  vocational  school  weekly  record,  Form  4,  shows  the  student's 
progress  in  vocational  education  and  his  qualifications  for  employ- 
ment. 


TRAINING    OF    TEACHERS   FOR    OCCUPATIONAL    THERAPY, 


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THIS  BOOK  IS  DUE  ON  THE  LAST  DATE 
STAMPED  BELOW 


AN  INITIAL  FINE  OF  25  CENTS 

WILL  BE  ASSESSED  FOR  FAILURE  TO  RETURN 
THIS  BOOK  ON  THE  DATE  DUE.  THE  PENALTY 
WILL  INCREASE  TO  SO  CENTS  ON  THE  FOURTH 
DAY  AND  TO  $1.OO  ON  THE  SEVENTH  DAY 
OVERDUE. 


MAR    6    l«4b 

MAY  13  1946 

IMTCDI  IDD  AOV  I  r*\AHi 

INTcRUBRARY  LOAN 

OflT  Z  2  1390 

i  twiv  nr  TAI  IP  RFBK 

"wsrur 

NOV  ?  8  nQ4 

11  V  f    £    O     HJ3T 

U.C.BERKiLlY 

LD  21-100m-12,'43  (8796s) 

Gaylord  Bros. 

Makers 

Syracuse,  N.  Y. 
PM.  JAN.  21,1908 


YC 


371847 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 


